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1.  Unusual presentation of peritonitis with persistent clear aspirate: a case report 
Peritonitis is the most frequent complication of peritoneal dialysis. Diagnosis of peritonitis includes symptoms and signs of peritonitis with a cloudy aspirate of more than 100 WBC/ml, as well as positive cultures. Although sterile peritonitis has been reported in the literature, to the best of our knowledge this is the first report of an unusual presentation of peritonitis without any white blood cells in the peritoneal aspirate despite multiple positive peritoneal cultures.
Case presentation
An 82-year-old Caucasian man who had been on continuous cycling peritoneal dialysis for 12 years was admitted to our hospital with general malaise, loss of appetite, weight loss and somnolence. He did not describe abdominal pain or fever. Even though his peritoneal fluid was consistently negative for leukocytes and clear, he had peritonitis with different organisms consecutively.
Our case report shows that any patient on peritoneal dialysis presenting with evidence of infection (fever, peripheral leukocytosis) without an obvious cause should have aspirate cultures done even if the aspirate is clear and abdominal pain is absent. Our case report may change the initial work-up and management of these patients. We believe this report is of interest to general medicine and emergency room physicians as well as nephrologists.
PMCID: PMC3003677  PMID: 21110897
2.  An Extremely Uncommon Case of Parasitic Infection Presenting as Eosinophilic Ascites in a Young Patient 
Case Reports in Gastroenterology  2011;5(1):139-143.
We report the case of a 24-year-old male patient admitted for recent ascites and splenomegaly of unknown origin. The patient was referred to our institution with complaints of diarrhea, epigastric pain, abdominal cramping and weight loss over the past three weeks. The acute onset presented with colicky abdominal pain and peritoneal effusion. History revealed reduced appetite and weight gain of 7 kg over the last one month. His past medical history and family history was negative. He had no history of alcohol abuse or viral hepatitis infection. Laboratory data revealed normal transaminases and bilirubin levels, and alkaline phosphatase and gammaglutamyltransferase were within normal range. A diagnostic laparoscopy was performed which showed free peritoneal fluid and normal abdominal viscera. Upper gastrointestinal system endoscopy performed a few days later revealed diffuse severe erythematous pangastritis and gastroduodenal gastric reflux. Duodenal biopsies showed chronic nonspecific duodenitis. Antrum and corpus biopsies showed chronic gastritis. The ascitic fluid was straw-colored and sterile with 80% eosinophils. Stool exam was negative for parasitic infection. Treatment with albendazole 400 mg twice daily for 5 days led to the disappearance of ascites and other signs and symptoms. Three months after albendazole treatment the eosinophilic cell count was normal. The final diagnosis was consistent with parasitic infection while the clinical, sonographic and histological findings suggested an eosinophilic ascites. We emphasize the importance of excluding parasitic infection in all patients with eosinophilic ascites. We chose an alternative way (albendazole treatment) to resolve this clinical picture. With our alternative way for excluding this parasitic infection, we treated the patient and then found the cause.
PMCID: PMC3088738  PMID: 21552435
Eosinophilic ascites; Parasitic infection; Albendazole
3.  Gangrenous appendicitis presenting as acute abdominal pain in a patient on automated peritoneal dialysis: a case report 
Presentations of abdominal pain in patients on peritoneal dialysis deserve maximal attention and careful differential diagnosis on admittance to medical care. In this case report a gangrenous appendicitis in a patient on automated peritoneal dialysis is presented.
Case presentation
We report the case of a 38-year-old Caucasian man with end-stage renal disease who was on automated peritoneal dialysis and developed acute abdominal pain and cloudy peritoneal dialysate. Negative microbiological cultures of the peritoneal dialysis fluid and an abdominal ultrasonography misleadingly led to a diagnosis of culture negative peritonitis. It was decided to remove the peritoneal catheter but the clinical situation of the patient did not improve. An explorative laparotomy was then carried out; diffuse peritonitis and gangrenous appendicitis were found. An appendectomy was performed. Myocardial infarction and sepsis developed, and the outcome was fatal.
A peritoneal dialysis patient with abdominal pain that persists for more than 48 hours after the usual antibiotic protocol for peritoneal dialysis-related peritonitis should immediately alert the physician to the possibility of peritonitis caused by intra-abdominal pathology. Not only peritoneal catheter removal is indicated in patients whose clinical features worsen or fail to resolve with the established intra-peritoneal antibiotic therapy but, after 72 hours, an early laparoscopy should be done and in a case of correct indication (intra-abdominal pathology) an early explorative laparotomy.
PMCID: PMC3469333  PMID: 22989294
Abdominal pain; Appendicitis; Myocardial infarction; Peritoneal dialysis
4.  Spontaneous bacterial peritonitis in extrahepatic portal venous obstruction 
Spontaneous bacterial peritonitis is defined by a positive ascitic fluid bacterial culture and an elevated ascitic fluid absolute polymorphonuclear count (≥250 cells/mm3) without an evident intra-abdominal, surgically treatable source of infection. Transient ascites is well documented in patients with extrahepatic portal venous obstruction but spontaneous bacterial peritonitis complicating extrahepatic portal venous obstruction is extremely uncommon. The postulated reasons for the low incidence of spontaneous bacterial peritonitis in extrahepatic portal venous obstruction includes: lower incidence of ascites; intact hepatic reticuloendothelial system; and a relatively high ascitic fluid protein content. Here we report two cases of spontaneous bacterial peritonitis complicating extrahepatic portal venous obstruction.
PMCID: PMC3959491
Extrahepatic portal venous obstruction; spontaneous bacterial peritonitis; ascites
5.  Spontaneous biliary peritonitis, or delayed bile leak? 
Spontaneous biliary peritonitis is a rare cause of acute abdominal pain. Whilst usually of extrahepatic origin, here we describe an even rarer perforation of an intrahepatic duct.
Presentation of Case
A 31 year old woman presented with acute onset epigastric abdominal pain on a background of cholecystectomy four years prior. Laparoscopy demonstrated bilious fluid but failed to identify the site of bile leak. Subsequent ERCP localised the leak to an anomalous radical of the right hepatic duct.
Spontaneous biliary peritonitis is a rare diagnosis. Most cases are extrahepatic and the pathogenesis of intrahepatic ductal rupture has been difficult to define. Whilst acute bile leak is a recognised complication of cholecystectomy, bile leak four years following operation has not been described previously.
Spontaneous biliary peritonitis remains as a rare cause of acute abdominal pain. Within the context of cholecystectomy, the surgeon should always be alert to the possibility of delayed bile leak.
PMCID: PMC3199634  PMID: 22096716
Biliary peritonitis; Cholecystectomy; Bile leak
6.  Spontaneous bacterial peritonitis with a very high leukocyte count in ascitic fluid caused by Haemophilus influenzae 
We report on a case of spontaneous bacterial peritonitis (SBP) due to Haemophilus influenzae (H. influenzae) in an elderly patient with alcoholic cirrhosis. The patient presented with a 5 day history of fever, cough, and fatigue. Abdominal paracentesis revealed a very high neutrophil count (134,800 cells/μL). Secondary peritonitis and abdominal abscess were ruled out. Peritoneal fluid culture displayed the growth of H. influenzae. The patient was treated with ceftriaxone and showed signs of improvement. Eventually, the patient died due to septic shock caused by other organisms. H. influenzae is a very rare cause of SBP. This case report demonstrates that (1) H. influenzae should be considered a potential cause of SBP, and (2) a very high leukocyte count in ascitic fluid can be found in patients with SBP.
PMCID: PMC3751378  PMID: 23983486
cirrhosis; spontaneous bacterial peritonitis; Haemophilus influenzae
7.  Malignant peritoneal mesothelioma presenting as recurrent adhesion obstruction in general surgery: a case report 
Malignant peritoneal mesothelioma is a well-described entity in many reports in the literature in which it has been associated with asbestosis. However, there is no information describing the gross appearance and cardinal features seen during laparotomy, hence it is easy for the unwary surgeon to miss the diagnosis of this rare condition.
Case presentation
A 49-year-old man of African descent presented to our hospital with a three-month history of weight loss, anorexia, abdominal distension, and general signs of cachexia and ascites on second presentation. At first presentation one year prior to this, he had undergone a laparotomy at our institution by a different team for intestinal obstruction secondary to adhesions with no biopsy taken. The patient's condition subsequently progressively deteriorated, and investigations including upper and lower gastrointestinal endoscopies and computed tomography of the abdomen were inconclusive, except for some free fluid in the peritoneal cavity and diffuse, mild thickening of the gut wall and mesentery. A second-look exploratory laparotomy revealed widespread nodular thickening of the visceral peritoneum with a striking, uniformly diffuse, erythematous, and velvety appearance. The peritoneal biopsy histology showed that the patient had malignant peritoneal mesothelioma. His condition deteriorated rapidly, and he died eight weeks after surgery.
Our report aims to increase the diagnosing clinician's awareness of the cardinal features of malignant peritoneal mesothelioma and thus reduce diagnostic errors and delays in treatment.
PMCID: PMC3180415  PMID: 21878098
peritoneal mesothelioma; clinical appearance
8.  Eosinophilic ascites due to severe eosinophilic ileitis 
CytoJournal  2010;7:19.
There is a broad etiology for effusion eosinophilia that includes allergic, reactive, infectious, immune, neoplastic, and idiopathic causes. We report and describe the cytomorphologic findings of a rare case of eosinophilic ascites due to severe eosinophilic ileitis.
Case Presentation:
A 17-year-old male manifested acutely with eosinophilic ascites due to severe biopsy-proven subserosal eosinophilic ileitis. Isolated peritoneal fluid submitted for cytologic evaluation revealed that 65% eosinophils were present in a bloody background. The patient responded to corticosteroids, with complete resolution of his ascites.
Eosinophilic gastroenteritis with subserosal involvement should be added to the list of causes for eosinophils in peritoneal fluid. The finding of eosinophilic ascites, with appropriate clinical and laboratory findings, may warrant the need to perform laparoscopic intestinal biopsies to confirm the diagnosis.
PMCID: PMC2955351  PMID: 20976207
Ascites; cytology; eosinophilia; gastroenteritis; ileitis; peritoneal fluid; serosa
9.  A Case of Perforated Sigmoid Diverticulitis in Which Gram Staining of Ascitic Fluid Was Useful for Diagnosis 
Case Reports in Surgery  2014;2014:417987.
An 85-year-old woman was admitted to our hospital for steroid therapy for relapsing nephrotic syndrome. During hospitalization, she complained of sudden epigastric pain at night. Although there were signs of peritoneal irritation, CT showed a large amount of ascitic fluid, but no free intraperitoneal gas. Gram staining of ascitic fluid obtained by abdominal paracentesis showed Gram-negative rods, which raised a strong suspicion of gastrointestinal perforation and peritonitis. Therefore, emergency surgery was performed. Exploration of the colon showed multiple sigmoid diverticula, one of which was perforated. The patient underwent an emergency Hartmann's procedure. Imaging studies failed to reveal any evidence of gastrointestinal perforation, presenting a diagnostic challenge. However, a physician performed rapid Gram staining of ascitic fluid at night when laboratory technicians were absent, had a strong suspicion of gastrointestinal perforation, and performed emergency surgery. Gram staining is superior in rapidity, and ascitic fluid Gram staining can aid in diagnosis, suggesting that it should be actively performed. We report this case, with a review of the literature on the significance of rapid diagnosis by Gram staining.
PMCID: PMC3971547  PMID: 24716075
10.  Spontaneous rupture of a pancreatic acinar cell carcinoma presenting as an acute abdomen 
Pancreatic acinar cell carcinoma is a rare malignant pancreatic neoplasm. To the best of our knowledge, there has been no report on spontaneous rupture of acinar cell carcinoma.
A 39-year-old Azari male presented with a history of sudden onset, acute epigastric pain of 12-h duration. Eight hours later the patient's general condition rapidly deteriorated, blood pressure was decreased to 90/70 mm/Hg and heart rate was increased to 120 beat/min. Emergent abdominal computed tomography scan showed a well-defined hypo-dense, necrotic mass, measured 12 cm × 12 cm that was originating from the uncinate process of pancreas with marked free peritoneal fluid and extensive haziness of retroperitoneal and mesenteric fat compatible with marked bleeding. Emergent abdominal operation was performed and histopathology revealed acinar cell carcinoma of the pancreas.
Pancreatic acinar cell carcinoma (ACC) usually presents with abdominal pain, nausea and vomiting. To best of our knowledge, no report has been made of spontaneous rupture of ACC.
Pancreatic carcinoma may present as acute abdomen due to rupture of underlying neoplasm.
PMCID: PMC3356555  PMID: 22543229
Acinar cell carcinoma; Pancrease; Rupture
11.  Peritoneal adhesion: it can be life-threatening, and life-saving 
BMC Nephrology  2012;13:113.
The inevitable post-inflammatory fibrosis and adhesion often compromises future treatment in peritoneal dialysis patients. Here, we describe a patient who experienced an unusual form of peritoneal adhesion that made her give up peritoneal dialysis. However, its unique pattern also saved her from infection caused by bowel perforation.
Case presentation
The female patient discontinued peritoneal dialysis due to gradual dialysis inadequacy. Two months after shifting to hemodialysis with generally improved sense of well-being and no sign of abdominal illness, she was admitted to remove the Tenckhoff catheter. The procedure was smooth, but fever and abdominal pain not at the site of operation developed the next day. Abdominal ultrasound showed the presence of ascites and aspiration revealed slimy, green-yellowish pus that gave a negative result on bacterial culture. Abdominal computed tomography (CT) with oral contrast medium was performed, but failed to demonstrate the suspected bowel perforation. The examination, however, did show accumulation of pus inside the abdomen but outside the peritoneal cavity. We drained the pus with two 14-F Pig-tail catheters and the total amount of drainage approached 4000 ml. The second CT was performed with double dose of the contrast medium and found a leak of the contrast from the jejunum. She then received laparotomy and had the perforation site closed.
In summary, this uremic patient suffered from pus accumulation inside her abdomen without obvious systemic toxic effect. The bowel perforation and pus formation might be caused by repeated peritonitis, but the peritoneal adhesion itself might also isolate her peritoneal cavity from the anticipated toxic injuries of bowel perforation.
PMCID: PMC3506508  PMID: 22992203
Peritoneal dialysis; Peritonitis; Ultrafiltration failure; Peritoneal adhesion; Encapsulating peritoneal sclerosis
12.  Disseminated peritoneal leiomyomatosis with chronic constipation: a case report 
Disseminated peritoneal leiomyomatosis is a rare disease. Almost all disseminated peritoneal leiomyomatosis cases described in the literature are associated with a gynecological disorder or a mass in the abdominal cavity. Disseminated peritoneal leiomyomatosis with only chronic constipation has not been reported in the English literature. We present a case of a patient with disseminated peritoneal leiomyomatosis who manifested solely with chronic constipation.
Case presentation
A 49-year-old premenopausal nulliparous Caucasian woman was admitted with complaints of abdominal distention and chronic constipation. Open subtotal colectomy with ileorectal anastomosis was performed. There were diffuse nodular and polypoid tumor formations in her colonic mesoderm. Based on morphological and pathological evaluation of the resection material, she was diagnosed with disseminated peritoneal leiomyomatosis.
In general, disseminated peritoneal leiomyomatosis is seen in women who are of childbearing age with estrogen hypersecretion. Preoperative diagnosis of disseminated peritoneal leiomyomatosis is almost impossible and it can be confused with disseminated intra-abdominal malignancies. There are no specific methods to diagnose disseminated peritoneal leiomyomatosis in a preoperative period.
PMCID: PMC3977977
Abdominal distention; Abdominal pain; Chronic constipation; Disseminated peritoneal leiomyomatosis
13.  Systemic Reactive Amyloidosis Associated with Castleman's Disease 
Case Reports in Gastroenterology  2013;7(3):476-481.
We report this case of secondary amyloidosis associated with Castleman's disease. A 51-year-old man presented with systemic symptoms of generalized weakness, fatigue, unintended weight loss, anorexia and progressively worsening abdominal distension. On examination he was found to have an indurated right-sided submandibular mass and tense ascites. He was found to have multiorgan dysfunction with deranged liver function tests and renal failure. Ascitic fluid analysis revealed evidence of spontaneous bacterial peritonitis. Biopsy of the submandibular mass revealed angiofollicular lymph node hyperplasia consistent with a diagnosis of Castleman's disease. A subsequent liver biopsy showed extensive deposition of amyloid protein. Bone marrow biopsy also showed the presence of amyloid and increased kappa light chain-restricted plasma cells. The patient was not considered a candidate for chemotherapy or solid organ transplantation in view of active sepsis and poor physical condition. Secondary systemic amyloidosis complicating Castleman's disease is very rare. Untreated secondary systemic amyloidosis often has a rapidly fatal course, such as seen in our patient.
PMCID: PMC3843903  PMID: 24348320
Secondary amyloidosis; Castleman's disease; Systemic reactive amyloidosis; AA amyloidosis; Amyloidosis in Castleman's disease
14.  Sclerosing epithelioid fibrosarcoma as a rare cause of ascites in a young man: a case report 
Sclerosing epithelioid fibrosarcoma is a rare but distinct variant of fibrosarcoma that not only presents as a deep-seated mass on the limbs and neck but can also occur adjacent to the fascia or peritoneum, as well as the trunk and spine. We report the case of an intra-abdominal sclerosing epithelioid fibrosarcoma, which to best of the authors' knowledge has not been described previously. The patient discussed here developed lung metastases but is still alive 1-year post-diagnosis.
Case presentation
A 29-year-old man presented with a 2-week history of progressive abdominal distension and pain and was found to have marked ascites. A full liver screen was unremarkable with abdominal and chest computed tomography scans only confirming ascites. After a diagnostic laparotomy, biopsies were taken from the greater omentum and peritoneal nodules. Histopathology revealed a malignant tumour composed of sheets and cords of small round cells set in collagenized stroma. After further molecular investigation at the Mayo Clinic, USA, the diagnosis of a high-grade sclerosing epithelioid fibrosarcoma was confirmed.
Sclerosing epithelioid fibrosarcoma is an extremely rare tumour, which is often difficult to diagnose and which few pathologists have encountered. This case is particularly unusual because of the intra-abdominal origin of the tumour. Owing to the rarity of sclerosing epithelioid fibrosarcoma, there is no clear evidence regarding the prognosis of such a tumour, although sclerosing epithelioid fibrosarcoma is able to metastasize many years post-presentation. It is important that physicians and pathologists are aware of this unusual tumour.
PMCID: PMC2503998  PMID: 18657268
15.  Moraxella Catarrhalis peritonitis 
Peritonitis continues to be a major complication of peritonitis in peritoneal dialysis patients. Recent advances in connectology and better patient training have decreased the incidence of peritonitis in the last two decades. Peritonitis in PD patients is usually due to gram positive and less often due to gram negative organisms. Herein we report a case of peritonitis due to Moraxella Catarrhalis and review the literature on the diagnosis and treatment of this rare cause of peritonitis.
Case Report:
Our patient was a 56 year old man with end stage renal disease, on peritoneal dialysis, who was totally asymptomatic and on routine clinic visit was noted to have a high white blood cell count in his peritoneal fluid. Due to the nature of the organism, it took two weeks and two different microbiology laboratories to identify the organism and provide proper treatment.
Peritonitis is the major cause of peritoneal dialysis failure and prompt recognition of the causative agent is of crucial importance to the proper and timely management of this complication.
PMCID: PMC3616167  PMID: 23569477
Moraxella; peritonitis; dialysis
16.  Bacterial peritonitis caused by Listeria monocytogenes: Case report and review of the literature 
Although Listeria monocytogenes has been isolated from the gastrointestinal tract, it is an infrequent cause of bacterial peritonitis. Since 1963 only 23 cases of peritonitis caused by listeria have been reported. This report describes another case in a patient with cirrhosis and chronic renal failure and presents a review of the literature. Most (16) of the previous cases were cirrhotic while six were undergoing chronic ambulatory peritoneal dialysis. Eight patients were on immunosuppressive therapy. Blood cultures were positive in fewer than half (42%) of the cases and Gram stain of peritoneal fluid was positive only twice. The peritoneal fluid protein concentration was relatively high compared with other causes of bacterial peritonitis. Ampicillin was the drug most commonly used for treatment, and the majority of patients survived the acute infection.
PMCID: PMC3327371  PMID: 22514418
Bacterial peritonitis; Listeria monocytogenes
17.  Acute chylous peritonitis: Report of a case 
Acute chylous peritonitis, a rare condition, is defined as an abrupt chylous fluid accumulation in the peritoneal space in the absence of a significant underlying pathology. Diagnosis is difficult due to abrupt onset and accompanying acute abdomen signs.
Here we presented the case of a 32-year-old female patient who underwent laparoscopy due to acute abdomen findings and was diagnosed with acute chylous peritonitis. No underlying pathologies were detected, and only irrigation and drainage were applied. She was discharged unproblematically with a low-fat diet and somatostatin administration. No recurrence occurred, and no other pathologies were encountered during her 9-month visit.
Chylous fluid accumulation is reported to arise from various etiological factors such as trauma, chronic liver diseases, tuberculosis, filariasis, radiation, abdominal aorta surgery, different peritoneal infection and extended lymph node dissections. We have presented an acute chylous peritonitis case that was admitted with acute abdomen findings and followed up and treated with laparoscopy.
In conclusion, this case demonstrates the effectiveness of laparoscopy in acute abdomen cases in which a specific preoperative diagnosis cannot be made. Aspiration of the fluid and drainage comprise a sufficient therapy if a focus cannot be found. Postoperative somatostatin use may be beneficial.
PMCID: PMC3605483  PMID: 23500748
Acute chylous peritonitis; Laparoscopy; Acute abdomen
18.  Generalized Peritonitis Secondary to Spontaneous Perforation of Pyometra in a 63-Year-Old Patient 
Spontaneous perforation of pyometra resulting in generalized diffuse peritonitis is extremely uncommon. Herein, we report the case of a 63-year-old woman who presented to emergency department with a 2-day history of severe diffuse abdominal pain, high-grade fever, nausea, and vomiting. Acute abdomen series was done, and upright plain chest radiograph showed free air under diaphragm. A noncontrast-enhanced computed tomography scan showed a significantly distended fluid-filled uterus measuring 10 × 7.8 × 10 cm, in addition to a single focus of perforation involving the uterine fundus and associated with presence of free air within the nondependant area. No evidence of ascites or pelvi-abdominal lymphadenopathy was identified. A preoperative diagnosis of generalized peritonitis secondary to spontaneous perforation of uterus was established. Subsequently, patient underwent urgent exploratory laparotomy which revealed pus-filled uterus with perforated fundus. Diagnosis of generalized peritonitis secondary to spontaneous perforation of pyometra was established. Consequently, patient underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy, as well as thorough drainage and irrigation of pelvi-abdominal cavity. Postoperatively, patient was admitted to intensive care unit. Histopathological examination of uterus was negative for malignancy, and surgical culture grew Streptococcus constellatus. Patient had an uneventful recovery. Moreover, a brief literature review on pyometra is presented.
PMCID: PMC3773424  PMID: 24073347
19.  Spontaneous intraperitoneal rupture of hepatic hydatid cyst with biliary peritonitis: a case report 
Cases Journal  2009;2:6511.
Spontaneous intraperitoneal rupture with biliary peritonitis in a case of hepatic hydatid cyst is extremely rare but serious complication. It is a surgical emergency with high morbidity and mortality rates. Very few cases have been reported in the literature.
Case presentation
We report an unusual case of a biliary peritonitis due to spontaneous rupture of hepatic hydatid cyst in a male patient of 34 years of age. He presented with acute peritonitis. Contrast enhanced computed tomography 2 days prior to laparotomy showed a dumbbell shaped hydatid cyst of right lobe of the liver with perihepatic fluid collection. At operation 1.5 L bile was found in the peritoneal cavity with rupture of the anterior wall of the cyst and large cystobiliary communication. He was managed with deroofing of the cyst, cholecystectomy, and placement of T tube in the cystobiliary communication and in the extrahepatic bile duct. He developed biliary fistula which was closed over a period of 34 days with conservative therapy. At 6 months follow up patient is well and free of recurrence.
Though rare, ruptured hydatid cyst should be considered in the differential diagnosis of acute abdomen in a patient residing in the endemic zone.
PMCID: PMC2769297  PMID: 19918527
20.  Delayed presentation of an isolated gallbladder rupture following blunt abdominal trauma: a case report 
Blunt injuries to the gallbladder occur rarely, and the incidence of isolated damage to the gallbladder is even smaller. We report a case of delayed presentation of isolated rupture of the gallbladder following blunt trauma to the abdomen.
Case presentation
A 65 year old lady presented through the Emergency Department with a 1 week history of blunt trauma to her abdomen. She complained of continued epigastric pain which radiated through to her back and right upper quadrant. On presentation, the patient had a low grade temperature, hypotension and mild tachycardia. Abdominal examination revealed right upper quadrant tenderness with no localised peritonism. C-reactive protein was 451. An abdominal CT showed a moderate amount of ascitic fluid in the perihepatic space. The patient underwent a laparotomy, which revealed a ruptured gallbladder with free bile. There was no evidence of any associated injuries to the surrounding organs. Partial cholecystectomy was done in view of the friable nature of the gallbladder. Post operatively, a persistent bile leak was managed successfully with endoscopic sphincterotomy and stenting.
Rupture of the gallbladder due to blunt injuries to the abdomen occurs from time to time and may constitute a diagnostic challenge especially with delayed presentation. Partial cholecystectomy is a safe option in cases where friability of the wall renders formal cholecystectomy inadvisable. Endoscopic sphincterotomy and stenting is a safe and effective treatment for persistent post operative bile leaks.
PMCID: PMC1936994  PMID: 17634139
21.  Acute abdomen caused by bladder rupture attributable to neurogenic bladder dysfunction following a stroke: a case report 
Spontaneous bladder rupture is a rare and serious event with high mortality. It is not often considered in the patient presenting with peritonitis. This often leads to delays in diagnosis. There are very few case reports of true spontaneous rupture in the literature. This is the first such reported case in which bladder rupture was attributable to neurogenic bladder dysfunction following a stroke.
Case presentation
We report the case of a 67-year-old Caucasian man who presented with lower abdominal pain and a peritonitic abdomen. He had a long-term urethral catheter because of urinary retention following a previous stroke. He was treated conservatively with antibiotics before a surgical opinion was sought. Exploratory laparotomy confirmed the diagnosis of spontaneous bladder rupture. After repair of the defect, he eventually made a full recovery.
In this unusual case report, we describe an example of a serious event in which delays in diagnosis may lead to increased morbidity and mortality. To date, no unifying theory explaining why rupture occurs has been postulated. We conducted a thorough literature search to examine the etiological factors in other published cases. These etiological factors either increase intra-vesical pressure or decrease the strength of the bladder wall. We hope that by increasing awareness of these etiological factors, spontaneous bladder rupture may be diagnosed earlier and appropriate therapy started.
PMCID: PMC3141706  PMID: 21714888
22.  Gastric perforation secondary to metastasis from ovarian cancer: Case report 
Metastasis from ovarian cancer occurs frequently through the peritoneal cavity in the form of peritoneal carcinomatosis; isolated gastric metastasis is rarely reported in literature.
We present a case of 43-year-old infertile lady, who developed a picture of acute abdomen four days post total abdominal hysterectomy and salpingoopherectomy for ovarian cancer. Further contrast-enhanced CT scan demonstrated massive free gas and fluid in the abdomen. She underwent antrectomy with truncal vagotomy due to 3 cm × 4 cm prepyloric gastric ulcer. Final pathology proved the presence of metastatic serous cystadenocarcinoma of ovarian origin.
Our patient had a gastric perforation secondary to ovarian metastasis. Being isolated, the absence of ascites and the transmural nature of the gastric metastasis suggest haematogenous spread .To the best of our knowledge perforated gastric metastasis secondary to ovarian cancer was not reported in literature before.
Gastric metastasis should be kept in mind in patients with a well-known ovarian cancer who present with gastric lesions, ulcers, bleeding or perforation.
PMCID: PMC3650261  PMID: 23608515
Ovarian cancer; Gastric perforation; Gastrointestinal metastasis
23.  T-Cell lymphoproliferative disorder of hand-mirror cell morphology presenting in an eosinophilic loculated peritoneal effusion, with omental "caking" 
CytoJournal  2006;3:13.
Cells with "hand mirror" morphology have not, to the best of our knowledge, been described in a primary effusion sample. This paper describes a case of T-cell lymphoma with eosinophilia in a patient with suspected peritoneal carcinomatosis. Rarely, a T-cell lymphoproliferative process may mimic primary peritoneal carcinomatosis, clinically suggested by a presentation in CT imaging of omental caking with bilateral massive loculated effusions in a patient without lymphadenopathy or splenomegaly.
A 60 year old caucasian male presented with vague abdominal discomfort and increasing abdominal girth. Computed tomography showed a two centimeter thick omental cake and a small loculated effusion. The clinical presentation and imaging findings were most consistent with peritoneal carcinomatosis. Cytologic evaluation of the effusion was undertaken for diagnostic study.
Rapid intraprocedural interpretation of the effusion sample showed a monomorphic population of cells with "hand-mirror" cell morphology exhibiting cytoplasmic extensions (uropodia) with 3–5 course dark cytoplasmic granules and a rim of vacuolated cytoplasm capping the opposing "mirror head" side. These cells were seen within a background of mature eosinophils. Flow cytometric evaluation of the ascites fluid demonstrated an atypical T-cell population with the following immunophenotype: CD2-, CD3+, CD4-, CD5-, CD7-, CD8+, CD56+. T-cell receptor (TCR) gene rearrangement was positive for clonal TCR-gamma gene rearrangement, supporting the diagnosis of a T-lymphoprolifereative disorder.
A T-cell lymphoproliferative process may present with "hand mirror" morphology in an effusion sample. These cells may show polar cytoplasmic vacuolization and 3–5 course granules within the "handle" of these unique cells. Cytoplasm shows peripheral constriction around the nucleus.
PMCID: PMC1524978  PMID: 16681858
24.  A spontaneously ruptured gastric stromal tumor with cystic degeneration presenting as hemoperitoneum: a case report. 
Journal of Korean Medical Science  2003;18(5):751-755.
We report a case of a 38-yr-old man with a spontaneously ruptured gastric stromal tumor presenting as hemoperitoneum in outpatient clinic. He visited our hospital with generalized abdominal pain after abdominal CT scan for the evaluation of the asymptomatic palpable abdominal mass. Repeated abdominal CT scan showed a size decrement of cystic mass compared with the previous abdominal CT scan, and newly developed fluid collection in the left paracolic gutter. An emergency laparotomy revealed a ruptured gastric stromal tumor with bloody fluid in the peritoneal cavity. Immunohistochemical examination revealed positive reactivity to C-kit protein and CD34. The patient presented with hemoperitoneum due to spontaneous rupture of the tumor, which is an extremely rare complication.
PMCID: PMC3055121  PMID: 14555833
25.  Acute chylous peritonitis due to acute pancreatitis 
We report a case of acute chylous ascites formation presenting as peritonitis (acute chylous peritonitis) in a patient suffering from acute pancreatitis due to hypertriglyceridemia and alcohol abuse. The development of chylous ascites is usually a chronic process mostly involving malignancy, trauma or surgery, and symptoms arise as a result of progressive abdominal distention. However, when accumulation of “chyle” occurs rapidly, the patient may present with signs of peritonitis. Preoperative diagnosis is difficult since the clinical picture usually suggests hollow organ perforation, appendicitis or visceral ischemia. Less than 100 cases of acute chylous peritonitis have been reported. Pancreatitis is a rare cause of chyloperitoneum and in almost all of the cases chylous ascites is discovered some days (or even weeks) after the onset of symptoms of pancreatitis. This is the second case in the literature where the patient presented with acute chylous peritonitis due to acute pancreatitis, and the presence of chyle within the abdominal cavity was discovered simultaneously with the establishment of the diagnosis of pancreatitis. The patient underwent an exploratory laparotomy for suspected perforated duodenal ulcer, since, due to hypertriglyceridemia, serum amylase values appeared within the normal range. Moreover, abdominal computed tomography imaging was not diagnostic for pancreatitis. Following abdominal lavage and drainage, the patient was successfully treated with total parenteral nutrition and octreotide.
PMCID: PMC3337577  PMID: 22563182
Chylous ascites; Chyloperitoneum; Chyle; Peritonitis; Pancreatitis

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