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Many causes of acute abdomen are diagnosed on computed tomography (CT). We present two cases of eosinophilic gastroenteritis that showed mural thickening of the stomach, duodenum, and/or proximal jejunum on CT. The correct diagnosis was made by checking the eosinophil count, and, in one case, unnecessary surgery was avoided.
Over the past 20 years, CT has become the premier imaging technique for evaluating patients presenting with symptoms of acute, severe, abdominal pain. The advent of multidector helical CT (MDCT) has improved the accuracy and expanded the indications for CT of the acute abdomen. MDCT is accurate for nearly all of the numerous etiologies of conditions that require emergency medical or surgical treatment. The proper execution and interpretation of CT in this setting reduces morbidity, mortality, and medical expenses.
A double labeling technique employing retrograde labeling of vagal neurons with horseradish peroxidase from injections into the stomach wall and immunocytochemistry for dopamine-beta-hydroxylase revealed catecholaminergic neurons in the medulla oblongata which project into the abdomen. The great majority of such neurons were located in the dorsal motor nucleus of the vagus, particularly in its rostral third.
The vascular skin territories over the anterior chest, the abdomen and thigh-inguinal region in man have been defined in vivo using selective angiography and the intra-arterial injection of Prostaglandin E1. With this method it was clear that the vascular skin territories represented the area of axial patterns. The technique had significant advantages over other conventional methods of definition of skin vascular territories. The survival area of axial pattern flaps was often far greater than the precise vascular skin territory of its axial vessels and the extent of this phenomenon appeared to depend mainly on the vascular pattern of the adjoining territories.
The use of the anteromedial thigh fasciocutaneous flap in the reconstruction of the lower abdomen and inguinal region is described. If there is a dominant vessel supplying the anteromedial thigh flap, it can be raised as an island or a free flap. When there are only slender vessels in this area, a random pattern fasciocutaneous flap can safely be created with a fasciosubcutaneous pedicle.
Intraabdominal lymphangiomas are rare. Most cases are asymptomatic, except when complicated. This is a case report of a 8-year-old boy with hemorrhage into a mesenteric lymphangioma following trauma, as a cause of acute abdomen. Prompt diagnosis and operation were imperative in the proper management of this child.
The unique clinical syndrome of uterus didelhphys with an obstructed hemivagina and ipsilateral renal agenesis, presenting as acute abdomen in three pubertal girls, is reported. Accurate preoperative diagnosis and appropriate treatment will offer relief of symptoms and decrease morbidity and unnecessary procedures.
Five neonates with esophageal atresia and absence of gas on abdominal radiographs were each found to have an apparently obliterated distal tracheoesophageal fistula without a long gap between the esophageal ends. Four were treated by primary repair of the esophagus, and one underwent esophageal replacement, although it is conceivable that primary repair could have been achieved if the correct diagnosis had been made at presentation. This variant of tracheoesophageal fistula can be expected in at least 14% of patients presenting with a gasless abdomen.
Interstitial pregnancy is an infrequent type of ectopic pregnancy. Two cases of acute abdomen due to ruptured interstitial pregnancy following salpingectomy, a rare event, are presented. Both patients were young women who had had a previous salpingo-oophorectomy due to ovarian cyst. The presenting symptoms were in the first case abdominal pain followed by hemorrhagic shock, and in the second a right iliac fossa syndrome simulating acute appendicitis. Surgical intervention consisted of wedge resection of the uterine segment involved. A review of the literature and practical considerations are presented.
Placenta percreta is a rare but serious complication of pregnancy, usually presenting itself in the third trimester. The incidence of fetal death and maternal mortality is high. We report a case presenting as an acute abdomen, due to haemoperitoneum at 33 weeks of pregnancy. Incidence, etiology, diagnosis and treatment are discussed, and the literature is reviewed.
Perforation of the urinary bladder without history of antecedent trauma is a rare clinical occurrence. However, in patients with acute conditions of the abdomen, especially those with previous voiding symptoms, the diagnosis should be considered. Three cases are reported. Patients presented with an atraumatic bladder perforation and peritonitis secondary to chronic inflammation, bladder outlet obstruction, and transitional cell carcinoma. After review of the literature, a classification of atraumatic bladder perforation has been revised to include presently available reports of this entity.
Ten patients with Stage III epithelial ovarian received whole abdomen radiation therapy after extensive courses of chemotherapy and second or third laparotomies. All patients had less than 2-mm diameter residual disease. The major side effect was bone marrow suppression which led to decreased dose or field size in four patients. Five patients have recurred and three of these have died. Further treatment after recurrence was compromised by bone marrow suppression. While 40-50% of selected patients may respond to this approach, numerous alternatives are being explored that would not handicap further treatment to the same degree and may have equal response rates.
A significant proportion of patients with epithelial ovarian carcinoma eventually fail after initial responses to chemotherapy. Further treatment with chemotherapy consisting of either the same combination or second-line regimens has been ineffective in producing durable responses. Thus, between June 1983 and June 1987, thirty patients with epithelial ovarian carcinoma who failed one or more chemotherapeutic regimens were treated with whole-abdominopelvic-cavity radiation therapy. Prior to the radiation the amount of residual disease after debulking was noted to be microscopic in 16 patients and macroscopic in 14 patients. Radiation was delivered with an open-field technique that extended from the domes of the diaphragm to the obturator foramina. Doses of 2500 cGy were planned to the whole abdomen, with a boost of another 2500 cGy to the pelvic and or paraaortic nodes when indicated. Higher doses were delivered to the areas of gross disease in the pelvis. Only 2 patients were unable to complete the planned therapy. Another 26% of the patients required interruption of the therapy secondary to hematologic toxicity but eventually completed the treatment. With an overall median follow-up of 14 months, 56% of the patients remain alive. Two-year actuarial survival and recurrence-free survival rates are 47 and 32%, respectively. The survival and recurrence-free survival rates for the group with microscopic residual disease--61 and 33%, respectively--are better than those for the patients with macroscopic residual disease--36 and 18%. The abdominopelvic cavity was the first site of failure in all but one of the 17 patients who have failed. In spite of the higher doses, pelvic failure alone or as a component occurred in 54% of the patients. Small bowel obstruction necessitating surgical intervention as a complication of therapy was seen in 13% of the patients.
The practical utilization of 3-D treatment planning to reduce doses to normal tissues in the abdomen is illustrated for irradiation of hepatic masses using fields with central axes rotated out of the transverse plane. The beams were arranged to go through the minimum amount of normal liver tissue, while exiting above or below a kidney. Although these beam arrangements were not coplanar with standard transverse body sections, they were designed for dose delivery through use of standard Megavoltage equipment. The planning process for these techniques illustrates the need for and use of several tools usually associated with 3-D treatment planning systems. Beam's eye-view planning with perspective display of the relevant anatomy in the projective beam geometry is required for designing the placement of focused blocks for these oblique fields. Three-dimensional volumetric dose calculations are required to evaluate dose distributions. Additionally, port-film-type radiographs, digitally reconstructed from the CT dataset, are found to be useful in understanding the correctness of simulation and verification films. The reduction in dose to normal tissues over that achievable using standard plans with beams entering the patient at right angles to the central axis of the body is illustrated using dose-volume histograms. These techniques have allowed the initiation of a radiation dose escalation protocol for tumors involving the liver and porta hepatis.
The absorption of radiolabeled soluble insulin ([125I]Actrapid Human; 10 U) from subcutaneous injection sites above (120 mm) and below (40 mm) the umbilicus was studied on 2 consecutive days in nine IDDM patients during 180 min. Insulin absorption was measured as disappearance of radioactivity by continuous external monitoring and as appearance of plasma immunoreactive free insulin (IRI). Adipose tissue blood flow (ATBF) was measured concomitantly by the 133Xe-washout technique. Plasma glucose was determined. Prior to the injections the depth of the subcutaneous fat tissue was determined using ultrasound. Significantly less radioactivity remained at the upper site, 42 +/- 5 vs. 60 +/- 6% after 180 min (P < 0.001). In accordance with this, injection into the site above vs. below the umbilicus resulted in a greater area under curve for plasma insulin, 3306 +/- 493 vs. 2357 +/- 466 mU/l per min (0-180 min; P < 0.01), and a more pronounced plasma glucose-lowering effect (P < 0.05). However, ATBF did not differ significantly between the two sites. These data suggest that there are clinically relevant differences in insulin absorption within the abdomen. Thus, insulin injection into the epigastric area causes more rapid insulin absorption resulting in an enhanced plasma glucose-lowering effect than injection into the more conventional site close beneath the umbilicus.
Heating patterns generated by a commercially available 13.5 MHz radiofrequency generator and induction coil hyperthermia system in human size phantoms and a 230 pound pig were studied using a multichannel computer-monitored thermometry system that is noninteractive in electromagnetic fields. The phantom studies were composed of synthetic muscle equivalent material and fresh tissue. The pig was heated in the regions of the upper abdomen and the midthorax, both under anesthesia and dead. The temperature was measured along fine penetrating catheters at 1 cm intervals in all experiments. In a homogeneous cylindrical phantom, under our measurement conditions, the temperature profile across the diameter is parabolic with marked superficial heating and essentially no central heating. In nonhomogeneous phantoms and in the pig, the symmetry of this profile was distorted but the basic pattern of marked superficial heating and nearly absent deep central heating remained. Blood flow in the living animal produced some thermal smoothing. It is considered probable that substantial radial temperature gradients will exist within eccentrically located human tumors heated with this device and that certain deep central tumors will be difficult or impossible to heat. Determination of its ultimate value for investigational; clinical hyperthermia studies will require accurate temperature mapping of tumors and normal tissues in various anatomic sites in comparison with other approaches to deep heating.
Twenty-two patients with acute abdominal symptoms were studied by abdominal sonography and by sonographically guided aspiration of intraperitoneal fluid. The colour of the fluid was found to be diagnostically valuable: a green colour indicated gallbladder perforation, a yellow colour was found in a variety of infectious diseases, a red colour in haemorrhagic pancreatitis or haemorrhage. Aspirating fluid from the peritoneal cavity under ultrasound guidance in connection with any routine ultrasound examination is a valuable and easy method for studying patients with symptoms of acute abdomen.
MRI with its excellent contrast resolution and direct multiplanar imaging has become a valuable medical tool in diagnostic imaging. Due to physiological motion artifacts, the role of MRI in the abdomen is still under discussion. The use of ultrafast sequences and the development of oral contrast agents, however, offers new promises for abdominal MRI. In the area of the retroperitoneum and pelvis, MRI produces excellent images as motion-artifacts are absent. Up to the end of 1989 clinical MRI in The Netherlands was performed in only four University hospitals; nevertheless these centers proved able to compete with international standards. The rapidly increasing number of MR units that recently became available in The Netherlands could result in a surpassing of CT in many pelvic and abdominal pathological conditions.