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1.  Mortality in a Case of Crystal Gel Ball Ingestion: An Alert for Parents 
Decorative crystal gel balls are used for decoration purpose. Due to their attractive appearance they may be ingested by children. This may result in grave complications. A case of decorative crystal ball ingestion is being reported in a 6 months old infant who presented with sub acute intestinal obstruction and was operated. Crystal gel balls were causing obstruction of jejunum. Enterotomy and removal of the mass of jelly balls was done with primary closure. The patient was re-operated for anastomotic disruption on 6th postoperative day. Baby developed septicemia, and succumbed after 2 days of second operation.
PMCID: PMC3418032  PMID: 22953300
Crystal balls;  Jelly balls;  Mortality
2.  Nontraumatic terminal ileal perforation 
Background
There is still confusion and controversy over the diagnosis and optimal surgical treatment of non traumatic terminal ileal perforation-a cause of obscure peritonitis.
Methods
This study was a prospective study aimed at evaluating the clinical profile, etiology and optimal surgical management of patients with nontraumatic terminal ileal perforation.
Results
There were 79 cases of nontraumatic terminal ileal perforation; the causes for perforation were enteric fever(62%), nonspecific inflammation(26%), obstruction(6%), tuberculosis(4%) and radiation enteritis (1%). Simple closure of the perforation (49%) and end to side ileotransverse anastomosis(42%) were the mainstay of the surgical management.
Conclusion
Terminal ileal perforation should be suspected in all cases of peritonitis especially in developing countries and surgical treatment should be optimized taking various accounts like etiology, delay in surgery and operative findings into consideration to reduce the incidence of deadly complications like fecal fistula.
doi:10.1186/1749-7922-1-7
PMCID: PMC1459268  PMID: 16759405
3.  Spectrum of Perforation Peritonitis 
Introduction: Perforation peritonitis mostly results from the perforation of a diseased viscus. Other causes of perforation include abdominal trauma, ingestion of sharp foreign body and iatrogenic perforation. The diagnosis is mainly based on clinical grounds. Plain abdominal X-rays (erect) may reveal dilated and oedematous intestines with pneumoperitoneum. Ultrasound and CT scan may diagnose up to 72% and 82% of perforation respectively. The present study was carried out to study various etiological factors, modes of clinical presentation, morbidity and mortality patterns of perforation peritonitis presented in the RIMS hospital, Imphal, India.
Material and Methods: The study was conducted from September 2010 to August 2012 on 490 cases of perforation peritonitis admitted and treated in the Department of Surgery. Initial diagnosis was made on the basis of detailed history, clinical examination and presence of pneumoperitoneum on erect abdominal X-ray.
Results: A total of 490 patients of perforation peritonitis were included in the study, with mean age of 48.28 years. 54.29% patients were below 50 years and 45.71% patients were above 50 years. There were 54.29% male patients and 45.71% female patients. Only 30% patients presented within 24 hours of onset of symptoms, 31.43% patients presented between 24 to 72 hours and 38.57% patients presented 72 hours after the onset of symptoms. Mean duration of presentation was 54.7 hours. Overall 469 patients were treated surgically and 21 patients were managed conservatively. Overall morbidity and mortality recorded in this study were 52.24% and 10% respectively.
doi:10.7860/JCDR/2013/5768.3596
PMCID: PMC3879863  PMID: 24392388
Perforation; Peritonitis; Presentation; Etiology; Morbidity; Mortality
4.  Acute abdomen caused by ingested chicken wishbone: a case report 
Cases Journal  2009;2:64.
Introduction
An ingested foreign body often passes the gastrointestinal tract without any complications. Foreign bodies, such as dentures, fish bones, chicken bones, and toothpicks, have been known to cause perforation of the GI tract.
Case presentation
We are presenting a case of a fifty-year-old male with acute abdomen; diffuse fibro purulent peritonitis, i.e. ileum perforation, caused by accidentally ingesting a chicken wishbone. He was treated surgically with ileum resection, and temporary ileostomy. After four months, intestinal continuity was established in the second operation.
Conclusion
Intestinal perforation by a chicken bone is rare and affects the left colon or distal ileum. The lack of information of ingestion and detection of chicken bones preoperatively are of interest to be considered in the differential diagnosis of acute abdomen, which in this case was treated surgically.
doi:10.1186/1757-1626-2-64
PMCID: PMC2633322  PMID: 19152706
5.  Rare cause of acute surgical abdomen with free intraperitoneal air: Spontaneous perforated pyometra. A report of 2 cases 
Summary
Background:
The acute abdomen accounts for up to 40% of all emergency surgical hospital admissions and a large proportion are secondary to gastrointestinal perforation. Studies have shown the superiority of the abdominal CT over upright chest radiographs in demonstrating free intraperitoneal air. Spontaneous perforated pyometra is a rare cause of the surgical acute abdomen with free intraperitoneal air. Only 38 cases have been reported worldwide.
Case Report:
We report 2 cases of spontaneously perforated pyometra in our hospital’s general surgery department. Both underwent exploratory laparotomy: one had a total hysterectomy and bilateral salpingo-oophorectomy, while the other had an evacuation of the uterine cavity, primary repair of uterine perforation and a peritoneal washout. A literature search was conducted and all reported cases reviewed in order to describe the clinical presentations and management of the condition. Of the 40 cases to date, including 2 of our cases, the most common presenting symptoms were abdominal pain (97.5%), fever (37.5%) and vomiting (25.0%). The main indication for exploratory laparotomy was pneumoperitoneum (97.5%).
Conclusions:
Pyometra is an unusual but serious condition in elderly women presenting with an acute abdomen. A high index of suspicion is needed to make the appropriate diagnosis.
doi:10.12659/AJCR.882629
PMCID: PMC3616039  PMID: 23569488
acute abdomen; free intra-peritoneal air; pyometra
6.  Medical treatment for a fish bone-induced ileal micro-perforation: A case report 
Ingested fish bone induced intestinal perforations are seldom diagnosed preoperatively due to incomplete patient history taking and difficulties in image evidence identification. Most literature suggests early surgical intervention to prevent sepsis and complications resulting from fish bone migrations. We report the case of a 44-year-old man suffered from acute abdomen induced by a fish bone micro-perforation. The diagnosis was supported by computed tomography (CT) imaging of fish bone lodged in distal ileum and a history of fish ingestion recalled by the patient. Medical treatment was elected to manage the patient’s condition instead of surgical intervention. The treatment resulted in a complete resolution of abdominal pain on hospital day number 4 without complication. Factors affecting clinical treatment decisions include the nature of micro-perforation, the patient’s good overall health condition, and the early diagnosis before sepsis signs develop. Micro-perforation means the puncture of intestine wall without CT evidence of free air, purulent peritoneum or abscess. We subsequently reviewed the literature to support our decision to pursue medical instead of surgical intervention.
doi:10.3748/wjg.v18.i41.5994
PMCID: PMC3491611  PMID: 23139620
Fish bone ingestion; Micro-perforation; Decision-making; Medical treatment; Small intestine
7.  Spontaneous Extra-Hepatic Bile Duct Perforation Postpartum 
Ghana Medical Journal  2013;47(4):204-207.
Summary
Spontaneous bile duct perforation is an unusual cause of acute abdomen. It is an extremely rare condition and rarely suspected or correctly diagnosed pre-operatively. A case of a 29year old adult female, presenting with peritonitis, 2days post partum is presented. Exploratory laparotomy showed biliary peritonitis secondary to a perforated common bile duct. She had a cholecystectomy and closure of the perforation over a T-tube. She recovered well and was discharged home. Awareness of spontaneous common bile duct perforation as a rare cause of biliary peritonitis, avoids undue delay in the diagnosis and thus improve prognosis. Cholecystectomy and drainage of bile duct using a T-tube is emphasized.
PMCID: PMC3961848  PMID: 24669027
Pregnancy; Pre-eclampsia; Peritonitis; Bile duct perforation; Cholangiogram
8.  Outcome after emergency surgery in patients with a free perforation caused by gastric cancer 
Perforation of gastric cancer is rare and it accounts for less than 1% of the incidences of an acute abdomen. In this study, we reviewed cases of benign or malignant gastric perforation in terms of the accuracy of diagnosis and investigated the clinical outcome after emergency surgery in patients with a free perforation caused by gastric cancer. On the basis of pathological examination, gastric cancer was diagnosed in 8 patients and benign ulcer perforation in 32 patients. The sensitivity, specificity and accuracy of intraoperative diagnosis by pathological examination were 50, 93.8 and 85%, respectively. Except for age, there were no differences in the other demographic characteristics between patients with gastric cancer and benign ulcer perforation. The median survival time of patients with perforated gastric cancer was 195 days after surgery. Patients with gastric cancer perforation had a poorer overall survival rate than those who had T3 tumors without perforation. In addition, in patients with perforation, recurrence of peritoneum occurred more frequently. In conclusion, to improve the survival rate of patients with perforated gastric cancer and to improve the accuracy of intraoperative diagnosis, endoscopic examination and/or pathological examination of the frozen section should be performed, if possible. A balanced surgical strategy using laparoscopic local repair as the first-step of surgery, followed by radical open gastrectomy with lymphadenectomy may be considered.
doi:10.3892/etm_00000032
PMCID: PMC3490384  PMID: 23136615
gastric cancer; perforation; prognosis; peritonitis
9.  Bowel Perforation by Crumpled Paper in a Patient Presenting with Acute Abdominal Pain 
Many of the abdominal foreign bodies are due to accidental ingestion. Our objective in this case report is to emphasize the importance of the enquiry about the foreign body in the differential diagnosis of acute abdominal pain. According to our knowledge, this is the first report of bowel perforation caused by paper ingestion. A 14-year-old boy with abdominal pain underwent exploratory laparotomy and was found to have abdominal pus and ileal perforation. A crumpled paper was found at the site of perforation. Postoperative enquiry revealed that the patient had ingested 10 crumpled papers. We highlight that recording the history is an important aspect in the management of patients with acute abdominal pain and that foreign bodies should be included in its differential diagnosis.
doi:10.4103/1319-3767.45060
PMCID: PMC2702949  PMID: 19568558
Acute appendicitis; foreign body; bowel perforation
10.  Gigantic hepatic amebic abscess presenting as acute abdomen: a case report 
Introduction
Amebiasis is a parasitic disease caused by Entamoeba histolytica. It most commonly results in asymptomatic colonization of the gastrointestinal tract, but some patients develop intestinal invasive or extra-intestinal diseases. Liver abscess is the most common extra-intestinal manifestation. The large number of clinical presentations of amebic liver abscess makes the diagnosis very challenging in non-endemic countries. Late diagnosis of the amebic abscess may lead to perforation and amebic peritonitis, resulting in high mortality rates.
Case presentation
This report describes a 37-year-old white man, suffering from hepatitis B, with a gigantic amebic liver abscess presenting as an acute abdomen due to its rupture. Rapid deterioration of the patient's condition and acute abdomen led to an emergency operation. A large volume of free fluid together with debris was found at the moment of entry into the peritoneal cavity because of a rupture of the hepatic abscess at the position of the segment VIII. Surgical drainage of the hepatic abscess was performed; two wide drains were placed in the remaining hepatic cavities and one on the right hemithorax. The patient was hospitalized in the ICU for 14 days and for another 14 days in our department. The diagnosis of amebic abscess was made by the pathologists who identified E. histolytica in the debris.
Conclusion
Acute abdomen due to a ruptured amebic liver abscess is extremely rare in western countries where the parasite is not endemic. Prompt diagnosis and treatment are fundamental to preserving the patient's life since the mortality rates remain extremely high when untreated, even nowadays.
doi:10.1186/1752-1947-2-325
PMCID: PMC2572068  PMID: 18847505
11.  "Golf ball liver": agent orange hepatitis. 
Gut  1997;40(5):687-688.
2,4-Dichlorophenoxyacetic acid (2,4-D) is a selective weedkiller which works by uncoupling oxidative phosphorylation and is in widespread use. It is known as "agent orange". A 65 year old man had acute hepatitis, thought to be caused by exposure to 2,4-D. The patient ingested 2,4-D as a result of habitual licking of his golf ball. Clinical and histological data together with a challenge test confirmed the diagnosis of "golf ball liver".
Images
PMCID: PMC1027176  PMID: 9203952
12.  An Unusual Etiology of Spontaneous Pyometra Perforation; A Case Report 
Introduction
By presenting this case we aimed to describe an uncommon complication of generalized peritonitis following spontaneous pyometra perforation in untreated cervical carcinoma.
Case Presentation
This report describes a 60-year-old postmenopausal woman presenting with clinical features mimicking intestinal perforation who was later diagnosed as cervical carcinoma with pyometra perforation at exploratory laparotomy. The patient had good post-operative recovery following drainage and peritoneal lavage.
Conclusion
Spontaneous pyometra perforation in a case of untreated carcinoma of cervix is a rare condition, yet it should be suspected and kept in the differential diagnosis of acute abdomen in elderly women.
PMCID: PMC3719291  PMID: 23926508
Acute abdomen; Cervical cancer; Perforation; Pyometra
13.  Spontaneous Rupture of Pyometra 
Spontaneous perforation is a very rare complication of pyometra. The clinical findings of perforated pyometra are similar to perforation of the gastrointestinal tract and other causes of acute abdomen. In most cases, a correct and definite diagnosis can be made only by laparotomy. We report two cases of diffuse peritonitis caused by spontaneous perforated pyometra. The first case is a 78-year-old woman with abdominal pain for which laparotomy was performed because of suspected incarcerated hernia. The second case is a 61-year-old woman with abdominal pain for which laparotomy was performed because of symptoms of peritonitis. At laparotomy of both cases, 1 liter of pus with the source of uterine was found in the abdominal cavity. The ruptured uterine is also detected. More investigations revealed no malignancy as the reason of the pyometra.
doi:10.1155/2013/298383
PMCID: PMC3760260  PMID: 24024054
14.  Atypical Presentation of Perforated Sigmoid Diverticulitis in a Kidney Transplant Recipient with Autosomal Dominant Polycystic Kidney Disease 
Perforated sigmoid diverticulitis, a complication of colonic diverticulosis commonly associated with autosomal dominant polycystic kidney disease (ADPKD), can be life-threatening in allogeneic kidney transplant recipients in the postoperative period. Immunosuppressive medications not only place the patient at risk for intestinal perforation, but also mask classic clinical symptoms and signs of acute abdomen, and subsequently lead to delayed diagnosis and treatment. We report a case of an ADPKD patient post kidney transplantation presenting with nausea, vomiting, and abdominal pain without signs of peritonitis. Chest x-ray revealed free air under the diaphragm consistent with intestinal perforation. Post kidney transplant recipients with ADPKD presenting with abdominal pain should prompt a search for possible perforated colonic diverticulitis in order to diagnose and treat this life-threatening condition early.
PMCID: PMC3727570  PMID: 23901392
autosomal dominant polycystic kidney disease (ADPKD); diverticulitis; diverticulosis; kidney transplant
15.  Fecal Impaction: A Cause for Concern? 
Fecal impaction (FI) is a common cause of lower gastrointestinal tract obstruction lagging behind stricture for diverticulitis and colon cancer. It is the result of chronic or severe constipation and most commonly found in the elderly population. Early recognition and diagnosis is accomplished by way of an adequate history and physical examination in conjunction with an acute abdominal series. Prompt identification and treatment minimizes the risks of complications such as bowel obstruction leading to aspiration, stercoral ulcers, perforation, and peritonitis. Treatment options include gentle proximal softening in the absence of complete bowel obstruction, distal washout, and manual extraction. Surgical resection of the involved colon or rectum is reserved for cases of FI complicated by ulceration and perforation leading to peritonitis. Recurrence is common, and can be managed by increasing dietary fiber content to 30 gm/day, increased water intake, and discontinuation of medications that can contribute to colonic hypomotility.
doi:10.1055/s-0032-1301760
PMCID: PMC3348734  PMID: 23449376
fecal impaction; constipation; stercoral perforation; inspissated stool syndrome
16.  Jejunal Diverticular Perforation due to Enterolith 
Case Reports in Gastroenterology  2011;5(2):445-451.
Jejunal diverticulosis is a rare entity with variable clinical and anatomical presentations. Although there is no consensus on the management of asymptomatic jejunal diverticular disease, some complications are potentially life-threatening and require early surgical treatment. Small bowel perforation secondary to jejunal diverticulitis by enteroliths is rare. The aim of this study was to report a case of small intestinal perforation caused by a large jejunal enterolith. An 86-year-old woman was admitted with signs of diffuse peritonitis. After initial fluid recovery the patient underwent emergency laparotomy. The surgery showed that she had small bowel diverticular disease, mainly localized in the proximal jejunum. The peritonitis was due to intestinal perforation caused by an enterolith 12 cm in length, localized inside one of these diverticula. The intestinal segment containing the perforated diverticulum with the enterolith was removed and an end-to-end anastomosis was done to reconstruct the intestinal transit. The patient recovered well and was discharged from hospital on the 5th postoperative day. There were no signs of abdominal pain 1 year after the surgical procedure. Although jejunal diverticular disease with its complications, such as formation of enteroliths, is difficult to suspect in patients with peritonitis, it should be considered as a possible source of abdominal infection in the elderly patient when more common diagnoses have been excluded.
doi:10.1159/000330842
PMCID: PMC3180661  PMID: 21960947
Diverticulum; Intestines; Lithiasis; Intestinal perforation; Diverticulitis
17.  Anticipatory effects of intonation: Eye movements during instructed visual search 
Journal of memory and language  2008;58(2):541-573.
Three eye-tracking experiments investigated the role of pitch accents during online discourse comprehension. Participants faced a grid with ornaments, and followed pre-recorded instructions such as “Next, hang the blue ball” to decorate holiday trees. Experiment 1 demonstrated a processing advantage for felicitous as compared to infelicitous uses of L+H* on the adjective noun pair (e.g. blue ball followed by GREEN ball vs. green BALL). Experiment 2 confirmed that L+H* on a contrastive adjective led to ‘anticipatory’ fixations, and demonstrated a “garden path” effect for infelicitous L+H* in sequences with no discourse contrast (e.g. blue angel followed by GREEN ball resulted in erroneous fixations to the cell of angels). Experiment 3 examined listeners’ sensitivity to coherence between pitch accents assigned to discourse markers such as ‘And then,’ and those assigned to the target object noun phrase.
doi:10.1016/j.jml.2007.06.013
PMCID: PMC2361389  PMID: 19190719
18.  A formula for comparison of selected sport ball compressibility. 
The purpose of this study was to develop a formula to determine and compare the compressibility of selected sport balls. Six balls (basketball, volleyball, soccer ball, baseball, handball, golf ball) were dropped ten times from each of four different heights onto a smooth solid surface overlaid with a white sheet of typing paper, overlaid with a sheet of carbon paper. The diameter of the area of contact of each ball imprinted onto the typing paper was measured in millimetres with calipers. From the data, the distance (d) that each ball compressed for each velocity (v) was calculated. It was found that a linear relationship existed between velocity at impact and the distance for each ball studied. The compressibility coefficient (c) for each ball was calculated and a formula was developed to determine the distance each ball would compress at a given velocity. When velocity is measured in metres per second and the distance a ball compresses is measured in millimetres, the formula to determine d for selected balls, in order of compressibility is: basketball d = 3.07v, volleyball d = 2.90v, soccer ball d = 2.80v, baseball d = 0.77v, handball d = 0.53v, and golf ball d = 0.17v.
PMCID: PMC1478814  PMID: 1913029
19.  Comparative analysis of primary repair vs resection and anastomosis, with laparostomy, in management of typhoid intestinal perforation: results of a rural hospital in northwestern Benin 
BMC Gastroenterology  2013;13:102.
Background
The objective is to compare primary repair vs intestinal resection in cases of intestinal typhoid perforations. In addition, we hypothesised the usefulness of laparostomy for the early diagnosis and treatment of complications.
Methods
111 patients with acute peritonitis underwent emergency laparotomy: number of perforations, distance of perforations from the ileocaecal valve, and type of surgery performed were recorded. A laparostomy was then created and explored every 48 to 72 hours. The patients were then divided into two groups according to the surgical technique adopted at the initial laparotomy: primary repair (Group A) or intestinal resection with anastomosis (Group B). Clinical data, intraoperative findings, complications and mortality were evaluated and compared for each group.
Results
In 104/111 patients we found intestinal perforations, multiple in 47.1% of patients. 75 had primary repair (Group A) and 26 had intestinal resection with anastomosis (Group B). Group B patients had more perforations than patients in Group A (p = 0.0001). At laparostomy revision, the incidence of anastomotic dehiscence was greater than that of primary repair dehiscence (p = 0.032). The incidence of new perforations was greater in Group B than in Group A (p = 0.01). Group B correlates with a higher morbility and with a higher number of laparostomy revisions than Group A (p = 0.005).
There was no statistical difference in terms of mortality between Group A and Group B. Presence of pus in the abdominal cavity at initial laparotomy correlates with significantly higher mortality (p = 0.0001).
Conclusions
Resection and anastomosis shows greater morbidity than primary repair. Laparostomy revision makes it possible to rapidly identify new perforations and anastomotic or primary repair dehiscences; although this approach may seem aggressive, the number of operations was greater in patients who had a favourable outcome, and does not correlate with mortality.
doi:10.1186/1471-230X-13-102
PMCID: PMC3691877  PMID: 23782915
20.  Spontaneous Intrahepatic Type II Gallbladder Perforation: A Rare Cause of Liver Abscess – Case Report 
A liver abscess formation is a rare complication of a gallbladder perforation, with a cholecystohepatic communication. Niemeier, in 1934, classified free gallbladder perforations and generalised biliary peritonitis as an acute or a Type I gallbladder perforation, a pericholecystic abscess and localised peritonitis as a subacute or a Type II gallbladder perforation, and cholecystoenteric fistulas as chronic or Type III gallbladder perforations. We are describing a 50–year–old male patient who presented with right upper quadrant pain and was found to have an intrahepatic perforation of the gallbladder. Our patient had a Type II perforation. We have discussed the diagnostic work-up and the management of this rare entity. Due to the high mortality that can be caused by a delay in making the correct diagnosis, a gallbladder perforation represents a special diagnostic and surgical challenge.
doi:10.7860/JCDR/2013/6069.3389
PMCID: PMC3809666  PMID: 24179927
Gallbladder perforation; Liver abscess; Niemeier classification
21.  Asymptomatic large left-atrial ball thrombus. Secondary to mitral stenosis. 
Texas Heart Institute Journal  1997;24(4):376-378.
We describe the very unusual case of a patient with a large, free-floating left-atrial thrombus secondary to severe mitral stenosis, in whom the peculiar symptoms and complications of a ball thrombus were absent. The patient's only symptom before the episode reported here was mild dyspnea, which was attributed to mitral stenosis. She experienced neither embolism nor syncope. While even her clinical signs did not indicate a left-atrial ball thrombus, both echocardiography and angiography showed a free-floating thrombus. Because of the risk of stroke and acute obstruction of the mitral valve, emergency surgery was performed upon diagnosis of the ball thrombus. The surgery, which consisted of removing the thrombus and replacing the mitral valve with a mechanical prosthesis, was uneventful. A computed tomographic brain scan prior to discharge did not detect any cerebral infarction.
Images
PMCID: PMC325486  PMID: 9456496
22.  Typhoid Intestinal Perforation: 24 Perforations in One Patient 
Intestine perforation is one of the most dreaded and common complication of typhoid fever remarkably so in developing world; it usually leads to diffuse peritonitis, requiring early surgical intervention. Despite various measures such as safe drinking water supply and safe disposal of waste, intestinal perforation from salmonellosis remains the most common emergency surgery performed. The incidence continues to rise, so also the mortality, despite new antibiotics and improvement in surgical technique. More disturbing is that we now see increasing number of ileal perforations and colonic involvement. We hereby present a case report of 35-year-old male with multiple (24) intestinal perforation in the Ileum and Cecum.
doi:10.4103/2141-9248.121220
PMCID: PMC3853607  PMID: 24349848
Asia; Multiple ileal perforations; Salmonellosis
23.  Distal radial fractures in young goalkeepers: a case for an appropriately sized soccer ball 
Objectives—To assess the rate of wrist fractures in young goalkeepers sustained by the specific mechanism of "saving the ball" and the potential influence of ball size and environmental conditions.
Methods—A prospective, clinic based study in one institution over a 17 month period. Patients were identified by specific questioning. Information on play circumstances and subsequent clinical progress was documented.
Results—Twenty nine fractures of the distal radius were identified in young goalkeepers (age range 6–15 years) as a direct result of saving the ball. Most were managed simply in a plaster cast. Three patients required minor surgical interventions, and all fractures went on to unite without significant complications. Where ball size was known, 12 of the 15 fractures in children aged 11 years or less occurred as the result of impact with an adult sized ball compared with three when a junior ball was involved. This is statistically significant (p = 0.039). In the 10 children aged 12–15 years, only one fracture involved a junior ball; this is also statistically significant (p = 0.027). Six of the injuries (21%) occurred when the ball was kicked by an adult. Injuries occurred in both organised and informal games throughout the year.
Conclusions—This specific mechanism of injury has not been widely acknowledged nor has the potential influence of ball size as a causative factor been examined. Recommendations for an appropriately sized soccer ball for young players exist but are not in universal use. Increased awareness of this particular injury mechanism is required.
Key Words: soccer; goalkeeper; fracture; distal radius; children
doi:10.1136/bjsm.35.6.409
PMCID: PMC1724423  PMID: 11726476
24.  Gallbladder perforation: A rare complication of enteric fever☆ 
INTRODUCTION
Gallbladder perforation is a rare complication of acute calculous cholecystitis in adults. Perforation of gallbladder due to enteric fever is extremely rare condition. Pre-operative diagnosis is rarely made and mortality is high.
PRESENTATION OF CASE
We report a case of acalculous gallbladder perforation following enteric fever in a 14-year-old boy, who presented as acute abdomen and responded very well after emergency laparotomy and cholecystectomy.
DISCUSSION
Enteric fever is common in tropics and a common cause of bowel perforation. Acute cholecystitis is a rare complication of typhoid and gallbladder perforation is extremely rare complication. Ultrasound and CT lack specificity to detect gallbladder perforation. Diagnosis is usually made intra-operatively. Cholecystectomy is treatment of choice in such cases and provides good result.
CONCLUSION
Gallbladder perforation secondary to enteric fever requires a high degree of clinical suspicion. In typhoid endemic region, it should be considered as a differential diagnosis in patient presenting with a history of prolonged fever and signs of peritonitis. Early diagnosis and immediate surgical intervention are very important in reducing the morbidity and mortality. Cholecystectomy is the choice with a good outcome.
doi:10.1016/j.ijscr.2013.12.004
PMCID: PMC3921641  PMID: 24441441
Gallbladder; Perforation; Enteric fever
25.  Laparoscopic Suture Repair of a Perforated Gastric Ulcer in a Severely Cirrhotic Patient With Portal Hypertension: First Case Report 
Background:
Open digestive surgery in cirrhotic patients is associated with high morbidity and mortality. Laparoscopy in this setting has the potential to reduce postoperative complications. Laparoscopic treatment of a perforated gastric ulcer in a severely cirrhotic patient with portal hypertension is herein described.
Methods:
A 75-year-old woman affected by cirrhosis of the liver (Child class C) and chronic gastric ulcer presented with acute abdominal pain. The diagnosis of perforation was made with plain films of the abdomen and computed tomography. Diagnostic laparoscopy showed intense peritonitis due to a perforated ulcer of the anterior gastric wall, 2 cm proximal to the pylorus. Suture closure and placement of an omental patch were performed laparoscopically.
Results:
Postoperative recovery was complicated by a minor leak of the gastric suture, managed by total parenteral nutrition. Closure of the gastric wound was demonstrated by Gastrografin studies on the 10th postoperative day. The patient was discharged on the 16th postoperative day. At 3-months follow-up, the patient is alive and free of gastric disease.
PMCID: PMC3021346  PMID: 14626407
Liver Cirrhosis; Perforated peptic ulcer; Laparoscopy

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