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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.  Spontaneous free perforation of the small intestine in adults 
Spontaneous free perforation of the small intestine is uncommon, especially if there is no prior history of visceral trauma. However, free, even recurrent, perforation may complicate a defined and established clinical disorder, such as Crohn’s disease. In addition, free perforation may be the initial clinical presentation of an occult intestinal disorder, such as a lymphoma complicating celiac disease, causing diffuse peritonitis and an acute abdomen. Initial diagnosis of the precise cause may be difficult, but now has been aided by computerized tomographic imaging. The site of perforation may be helpful in defining a cause (e.g., ileal perforation in Crohn’s disease, jejunal perforation in celiac disease, complicated by lymphoma or collagenous sprue). Urgent surgical intervention, however, is usually required for precise diagnosis and treatment. During evaluation, an expanding list of other possible causes should be considered, even after surgery, as subsequent management may be affected. Free perforation may not only complicate an established intestinal disorder, but also a new acute process (e.g., caused by different infectious agents) or a longstanding and unrecognized disorder (e.g., congenital, metabolic and vascular causes). Moreover, new endoscopic therapeutic and medical therapies, including use of emerging novel biological agents, have been complicated by intestinal perforation. Recent studies also support the hypothesis that perforation of the small intestine may be genetically-based with different mutations causing altered connective tissue structure, synthesis and repair.
doi:10.3748/wjg.v20.i29.9990
PMCID: PMC4123378  PMID: 25110427
Free small bowel perforation; Crohn’s disease; Non-traumatic perforation; Celiac disease; Small bowel lymphoma; Vasculitis; Collagenous sprue; Biological agents; Monoclonal antibodies
3.  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
4.  Management of rectal foreign bodies 
Background
Entrapped anorectal foreign bodies are being encountered more frequently in clinical practice. Although entrapped foreign bodies are most often related to sexual behavior, they can also result from ingestion or sexual assault.
Methods
Between 1999 and 2009, 15 patients with foreign bodies in the rectum were diagnosed and treated, at Izmir Training and Research Hospital, in Izmir. Information regarding the foreign body, clinical presentation, treatment strategies, and outcomes were documented. We retrospectively reviewed the medical records of these unusual patients.
Results
All patients were males, and their mean age was 48 years (range, 33–68 years). The objects in the rectum of these 15 patients were an impulse body spray can (4 patients), a bottle (4 patients), a dildo (2 patient), an eggplant (1 patient), a brush (1 patient), a tea glass (1 patient), a ball point pen (1 patient) and a wishbone (1 patient, after oral ingestion). Twelve objects were removed transanally by anal dilatation under general anesthesia. Three patients required laparotomy. Routine rectosigmoidoscopic examination was performed after removal. One patient had perforation of the rectosigmoid and 4 had lacerations of the mucosa. None of the patients died.
Conclusions
Foreign bodies in the rectum should be managed in a well-organized manner. The diagnosis is confirmed by plain abdominal radiographs and rectal examination. Manual extraction without anaesthesia is only possible for very low-lying objects. Patients with high- lying foreign bodies generally require general anaesthesia to achieve complete relaxation of the anal sphincters to facilitate extraction. Open surgery should be reserved only for patients with perforation, peritonitis, or impaction of the foreign body.
doi:10.1186/1749-7922-8-11
PMCID: PMC3601006  PMID: 23497492
Foreign body; Rectum; Anorectal trauma
5.  Abdominal Tuberculosis with an Acute Abdomen: Our Clinical Experience 
Introduction: Tuberculosis is an important cause of morbidity in India. Abdominal Tuberculosis is a great mimicker and is difficult to diagnose. This prospective observational study is based on those patients who were diagnosed to be suffering from Abdominal Tuberculosis only after they presented with an acute abdomen. This study aims to document the nature of different types of acute presentation in Abdominal Tuberculosis according to involved sites and surgical pathology. The study also discusses the indications and extent of surgical intervention.
Materials and Methods: Seventy new cases of Abdominal Tuberculosis (out of 718 cases of acute abdomen) were diagnosed and treated over a period of three years in the surgical ward of Calcutta National Medical College. Macroscopic appearance of abdominal tissues during surgery suggested the diagnosis of tuberculosis. The diagnosis was confirmed by histopathology and tissue culture. All patients were subsequently treated with a full course of antitubercular drugs (ATD).
Results: The clinical presentations of acute abdomen included acute intestinal obstruction, perforative peritonitis and acute appendicitis etc. Terminal ileum and ileocaecal region were predominantly involved. The most common pathology was intestinal stricture with or without perforation. Most of the patients (approx 78.5%) required emergency surgery as a therapeutic intervention. A two-stage procedure was preferred in peritonitis and sepsis. Most of the remaining patients (12.8%) required surgery after initial conservative treatment for the first few days. Undiagnosed Abdominal Tuberculosis represents a notable percentage (10%) of patients who present with an acute abdomen as a surgical emergency.
Conclusion: Abdominal Tuberculosis is very difficult to diagnose and diagnosis is often delayed till an acute abdomen is presented with. Almost all patients needed surgical intervention. Irrespective of surgery, all patients of abdominal tuberculosis require a full ATD.
doi:10.7860/JCDR/2014/8654.4574
PMCID: PMC4149105  PMID: 25177599
Abdominal tuberculosis with acute abdomen; Acute presentations of abdominal tuberculosis
6.  Role of laparoscopy in peritonitis 
Pakistan Journal of Medical Sciences  2013;29(4):1028-1032.
Objective: Laparoscopy has gained clinical acceptance in many subspecialties in the last decade. The conventional open surgery for peritonitis carries significant morbidity and mortality. The present study was done to extend and evaluate benefits of minimally invasive surgery in this subset of patients.
Methods: This was a prospective study spanning over a period of four years. All those patients diagnosed as having peritonitis on clinical assessment and preoperative investigations and those who were stable enough haemodynamically were included in this study. After initial resuscitation for few hours, they underwent diagnostic and therapeutic laparoscopy to identify the cause of peritonitis and to confirm the pathology. All cases were done under general anesthesia, using three standard ports at appropriate sites according to pathology. Patients were treated by different procedures either laparoscopically or with laparoscopic assistance after diagnosis. Operative and post operative data was collected and analyzed.
Results: Ninety two cases of peritonitis underwent diagnostic and therapeutic laparoscopy. Mean age of patient was 46.5 years. 24 patients were diagnosed as perforated duodenal, in 14 (58.3%) patients laparoscopic suture repair was done and in 8 (33.3%) small upper midline incision was given and perforation was repaired. Out of 32 patients having perforated appendix, 25 (78.1%) patients laparoscopic appendectomy was done while in 7 (21.8%) perforation was dealt by laparoscopic assistance. Out of 14 patients of ileal perforation 6 (42.8%) with minimal contamination laparoscopic suture was applied, while in 8 (57.1%), perforated loop was brought out by making small window and perforation was closed. All 22 patients with pelvic sepsis needed only aspiration of pus and peritoneal lavage. Only one patient died post operatively and 2 (2.1%) patients developed fistula. 6 (6.5%) patients developed port site infection.
Conclusion: Laparoscopic management is feasible, safe and effective surgical option for patients with peritonitis due to different abdominal emergencies in properly selected cases with higher diagnostic yield and a faster postoperative recovery.
PMCID: PMC3817755  PMID: 24353681
Peritonitis; Laparoscopy; Management
7.  Non-Traumatic Ileal Perforation: A Retrospective Study 
Objective:
To determine clinical features, operative findings and post-operative complications in patients operated for non-traumatic ileal perforation and to discuss the role of typhoid vaccination.
Materials and Methods:
A retrospective study was carried out from 2009-2010. Seven patients were admitted through casualty as cases of acute abdomen. Underlying conditions were typhoid ulcers (4 patients) and non-specific etiology (3 patients). Diagnosis was made on clinical grounds, laboratory investigations, radiology and operative findings. Exploratory laporotomy was done. Different variables studied post-operatively were wound infection, residual abscess, recurrence and delayed post-operative complications.
Results:
Tenderness, distension and rigidity were found in maximum patients. Gases under diaphragm and air fluid levels were common radiological findings. However, widal test and blood culture for S. typhi was positive in four patients. Six patients had single perforation and one patient had two perforations, all being on antimesentric border of ileum. Maximum patients had peritoneal collection of less than 1000 ml. In five patients simple closure of perforation was done and in remaining two resection with end to side ileotransverse anatomosis was required. Wound infection and residual intraabdominal abscess were found in one patient each.
Conclusion:
Management criteria remain same in typhoid and non-specific perforations. Commonest cause of ileal perforation is typhoid fever in our country, so immunization against typhoid beyond 18 years of age is recommended.
doi:10.4103/2249-4863.137633
PMCID: PMC4139993  PMID: 25161970
Ileal perforation; typhoid ulcer; typhoid vaccination
8.  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
9.  Appendectomy and Resection of the Terminal Ileum with Secondary Severe Necrotic Changes in Acute Perforated Appendicitis 
Patient: Female, 19
Final Diagnosis: Acute perforated appendicitis • appendiceal abscess • secondary necrosis of the ileal wall
Symptoms: Right lower quadrant abdominal pain • fever
Medication: —
Clinical Procedure: Diagnostic laparoscopy • open drainage of an appendiceal abscess • appendectomy • ileal resection
Specialty: Surgery
Objective:
Management of emergency care
Background:
Resectional procedures for advanced and complicated appendicitis are performed infrequently. Their extent can vary: cecal resection, ileocecectomy, and even right hemicolectomy. We present a very rare case of appendectomy that was combined with partial ileal resection for severe necrotic changes and small perforation of the ileum.
Case Report:
A 19-year-old female patient was hospitalized with right iliac fossa pain and fever 10 days after the onset of symptoms. On laparoscopy, a large mass in a right iliac fossa was found. The ultrasound-guided drainage of the suspected appendiceal abscess was unavailable. After conversion using McBurney’s incision, acute perforated appendicitis was diagnosed. It was characterized by extension of severe necrotic changes onto the ileal wall and complicated by right iliac fossa abscess. A mass was bluntly divided, and a large amount of pus with fecaliths was discharged and evacuated. Removal of necrotic tissues from the ileal wall led to the appearance of a small defect in the bowel. A standard closure of this defect was considered as very unsafe due to a high risk of suture leakage or bowel stenosis. We perform a resection of the involved ileum combined with appendectomy and drainage/tamponade of an abscess cavity. Postoperative recovery was uneventful. The patient was discharged on the 15th day.
Conclusions:
In advanced appendicitis, the involved bowel resection can prevent possible complications (e.g., ileus, intestinal fistula, peritonitis, and intra-abdominal abscess). Our case may be the first report of an appendectomy combined with an ileal resection for advanced and complicated appendicitis.
doi:10.12659/AJCR.892471
PMCID: PMC4307687  PMID: 25618525
Abdominal Abscess; Appendicitis; Intestine, Small
10.  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
11.  Spectrum of Perforation Peritonitis in Delhi: 77 Cases Experience 
The Indian Journal of Surgery  2012;75(2):133-137.
Perforation peritonitis is the most common surgical emergency encountered by surgeons all over the world as well in India. The spectrum of etiology of perforation peritonitis in tropical countries continues to differ from its western counterpart. This study was conducted at Hindu Rao Hospital, Municipal Corporation of Delhi, New Delhi, India, designed to highlight the spectrum of perforation peritonitis in the eastern countries and to improve its outcome. This prospective study included 77 consecutive patients of perforation peritonitis studied in terms of clinical presentations, causes, site of perforation, surgical treatment, postoperative complications, and mortality at Hindu Rao Hospital, Delhi, from March 1, 2011 to December 1, 2011, over a period of 8 months. All patients were resuscitated and underwent emergency exploratory laparotomy. On laparotomy cause of perforation peritonitis was found and controlled. The most common cause of perforation peritonitis noticed in our series was perforated duodenal ulcer (26.4 %) and ileal typhoid perforation (26.4 %), each followed by small bowel tuberculosis (10.3 %) and stomach perforation (9.2 %), perforation due to acute appendicitis (5 %). The highest number of perforations was seen in ileum (39.1 %), duodenum (26.4 %), stomach (11.5 %), appendix (3.5 %), jejunum (4.6 %), and colon (3.5 %). Overall mortality was 13 %. The spectrum of perforation peritonitis in India continuously differs from western countries. The highest number of perforations was noticed in the upper part of the gastrointestinal tract as compared to the western countries where the perforations seen mostly in the distal part. The most common cause of perforation peritonitis was perforated duodenal ulcer and small bowel typhoid perforation followed by typhoid perforation. Large bowel perforations and malignant perforations were least common in our setup.
doi:10.1007/s12262-012-0609-2
PMCID: PMC3644151  PMID: 24426408
Exploratory laparotomy; Emergency surgery; Perforation peritonitis; Primary repair; Stomas; Resection and anastomosis
12.  Performance and Kinematics of Various Throwing Techniques in Team-Handball 
In team-handball competition, the players utilize various throwing techniques that differ in the lower body movements (with and without run-up or jump). These different lower body movements influence changes in the upper body movements and thus also affect the performance. A comprehensive analysis of 3D-kinematics of team-handball throws that may explain these differences in performance is lacking. Consequently, the purpose of this study was (1) to compare performance (ball velocity and throwing accuracy) between the jump throw, standing throw with and without run-up, and the pivot throw; (2) to calculate the influence of kinematic parameters to ball velocity; and (3) to determine if these four throwing techniques differ significantly in kinematics. Three-dimensional kinematic data (angles, angular velocities and their timing, ball velocity and velocity of the center of mass) of 14 elite team-handball players were measured using an 8 camera Vicon MX13 motion capture system (Vicon, Oxford, UK), at 250 Hz. Significant difference was found between the four throwing techniques for ball velocity (p < 0. 001), maximal velocity of the center of mass in goal-directed movement (p < 0.001), and 15 additional kinematic variables (p < 0.003). Ball velocity was significant impacted by the run-up and the pelvis and trunk movements. Depending on floor contact (standing vs. jump throws), elite players in the study used two different strategies (lead leg braces the body vs. opposed leg movements during flight) to accelerate the pelvis and trunk to yield differences in ball velocity. However, these players were able to utilize the throwing arm similarly in all four throwing techniques.
Key pointsElite team-handball players achieved the greatest ball velocity in the standing throw with run-up (100%), followed by the standing throw without run-up (93%), jump throw (92%) and pivot throw (85%).Depending on the floor contact (standing vs. jump throws) the elite players of the study used two different strategies (lead leg braces the body vs. opposed leg movements during flight) to accelerate the pelvis and trunk that caused differences in ball velocity.Elite team-handball players were able to utilize the throwing arm similarly in all four throwing techniques.
PMCID: PMC3737895  PMID: 24149298
Ball games; biomechanics; ball velocity; throwing accuracy
13.  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
14.  Spectrum of perforation peritonitis in Pakistan: 300 cases Eastern experience 
Background
Perforation peritonitis is the most common surgical emergency encountered by the surgeons all over the world as well in Pakistan. The spectrum of etiology of perforation peritonitis in tropical countries continues to differ from its western counter part. This study was conducted at Dow University of health sciences and Civil Hospital Karachi (DUHS & CHK) Pakistan, designed to highlight the spectrum of perforation peritonitis in the East and to improve its outcome.
Methods
A prospective study includes three hundred consecutive patients of perforation peritonitis studied in terms of clinical presentations, Causes, site of perforation, surgical treatment, post operative complications and mortality, at (DUHS&CHK) Pakistan, from 1st September 2005 – 1st March 2008, over a period of two and half years. All patients were resuscitated underwent emergency exploratory laparotomy. On laparotomy cause of perforation peritonitis was found and controlled.
Results
The most common cause of perforation peritonitis noticed in our series was acid peptic disease 45%, perforated duodenal ulcer (43.6%) and gastric ulcer 1.3%. followed by small bowel tuberculosis (21%) and typhoid (17%). large bowel perforation due to tuberculosis 5%, malignancy 2.6% and volvulus 0.3%. Perforation due to acute appendicitis (5%). Highest number of perforations has seen in the duodenum 43.6%, ileum37.6%, and colon 8%, appendix 5%, jejunum 3.3%, and stomach 2.3%. Overall mortality was (10.6%).
Conclusion
The spectrum of perforation peritonitis in Pakistan continuously differs from western country. Highest number of perforations noticed in the upper part of the gastrointestinal tract as compared to the western countries where the perforations seen mostly in the distal part. Most common cause of perforation peritonitis is perforated duodenal ulcer, followed by small bowel tuberculosis and typhoid perforation. Majority of the large bowel perforations are also tubercular. Malignant perforations are least common in our setup.
doi:10.1186/1749-7922-3-31
PMCID: PMC2614978  PMID: 18992164
15.  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
16.  Colonoscopic perforation leading to a diagnosis of Ehlers Danlos syndrome type IV: a case report and review of the literature 
Introduction
Colonoscopic perforation is a rare but serious complication of colonoscopy. Factors known to increase the risk of perforation include colonic strictures, extensive diverticulosis, and friable tissues. We describe the case of a man who was found to have perforation of the sigmoid colon secondary to an undiagnosed connective tissue disorder (Ehlers-Danlos syndrome type IV) while undergoing surveillance for hereditary non-polyposis colorectal cancer.
Case presentation
A 33-year-old Caucasian man presented to our hospital with an acute abdomen following a colonoscopy five days earlier as part of hereditary non-polyposis colorectal cancer screening. His medical history included bilateral clubfoot. His physical examination findings suggested left iliac fossa peritonitis. A computed tomographic scan revealed perforation of the sigmoid colon and incidentally a right common iliac artery aneurysm as well. Hartmann's procedure was performed during laparotomy. The patient recovered well post-operatively and was discharged. Reversal of the Hartmann's procedure was performed six months later. This procedure was challenging because of dense adhesions and friable bowel. The histology of bowel specimens from this surgery revealed thinning and fibrosis of the muscularis externa. The patient was subsequently noted to have transparency of truncal skin with easily visible vessels. An underlying collagen vascular disorder was suspected, and genetic testing revealed a mutation in the collagen type III, α1 (COL3A1) gene, which is consistent with a diagnosis of Ehlers-Danlos syndrome type IV.
Conclusions
Ehlers-Danlos syndrome type IV, the vascular type, is a rare disorder caused by mutations in the COL3A1 gene on chromosome 2q31. It is characterized by translucent skin, clubfoot, and the potentially fatal complications of spontaneous large vessel rupture, although spontaneous uterine and colonic perforations have also been reported in the literature. The present case presentation describes the identification of Ehlers-Danlos syndrome type IV in a patient with a non-spontaneous colonic perforation secondary to an invasive investigation for another hereditary disorder pre-disposing him to colorectal cancer. Invasive procedures such as arteriograms and endoscopies are relatively contra-indicated in Ehlers-Danlos syndrome type IV. Alternatives with a lower risk of perforation, such as computed tomographic colonography, need to be considered for patients requiring ongoing colorectal cancer surveillance. Furthermore, management of vascular aneurysms in patients with Ehlers-Danlos syndrome type IV requires consideration of the risks of endovascular stenting, as opposed to open surgical intervention, because of tissue friability. Genetic and reproductive counseling should be offered to affected individuals and their families.
doi:10.1186/1752-1947-5-229
PMCID: PMC3141693  PMID: 21699676
17.  A pin in appendix within Amyand's hernia in a six-years-old boy: case report and review of literature 
Introduction
Presence of vermiform appendix (non-inflamed or inflamed) in inguinal hernia is called Amyand's hernia in honor to surgeon C. Amyand who published the first case of perforated appendicitis within inguinal hernia in a boy caused by ingested pin. This presentation of foreign body Amyand's hernia appendicitis is very rare, and here we present such a case.
Case presentation
A 6-year-old boy, white Kosovar ethnicity, presented with right groin pain, swelling and redness. Two days before admission the patient was injured by football during a children game in the right lower abdomen and the next day he complained of pain in the right inguinal area.
On admission patient had a painful non-reducible mass in the right inguinal region and cellulitis. Plain abdominal x-ray showed no fluid-air levels, but a metallic foreign body (pin) under right superior pubic ramus was apparent. With preoperative diagnosis of suspect incarcerated inguinal hernia with cellulitis the patient was operated on under general anaesthesia in December 2, 2006. Intraoperatively we found the inflamed vermiform appendix perforated by a pin in the hernial sac. Appendectomy and herniotomy were performed. The wound was primary closed, without any post-operative complications and follow up for the patient is three years long.
Conclusion
Foreign body (pin) Amyand's hernia appendicitis seems to be extremely rare, maybe once in a century (Amyand 1735, Hall 1886, and our case in 2006). In patients with clinical signs of incarcerated inguinal hernia, with locally inflammatory signs, but without signs of intestinal obstruction Amyand's hernia appendicitis in differential diagnosis must be considered. In our case, it is possible that the injury during the football game might have induced perforation of the vermiform appendix with the foreign body in it.
doi:10.1186/1749-7922-5-14
PMCID: PMC2882903  PMID: 20482877
18.  Ileal Intussusception Caused by Vanek's Tumor: A Case Report 
Case Reports in Gastroenterology  2011;5(1):110-116.
Inflammatory fibroid polyps (Vanek's tumor) are rare benign localized lesions originating in the submucosa of the gastrointestinal tract. Intussusceptions due to inflammatory fibroid polyps are uncommon; moreover, ileo-ileal intussusception with small bowel necrosis and perforation has rarely been reported. We report a 56-year-old woman who was admitted two days after complaints of nausea and vomiting. Abdominal examination revealed distension, signs of gastrointestinal perforation and clanging intestinal sounds. The patient underwent a emergency laparotomy which found a 17-cm invaginated mid-ileal segment with necrosis, perforation and fecal peritonitis. The ileal segment was resected and single-layer end-to-end anastomosis was performed. Histopathological analysis showed an ulcerative lesion with variable cellularity, formed by spindle cells with small number of mitosis and an abundant inflammatory infiltrate comprising mainly eosinophils. Immunohistochemistry confirmed the diagnosis of ileal Vanek's tumor. Although inflammatory fibroid polyps are seen very rarely in adults, they are among the probable diagnoses that should be considered in obstructive tumors of the small bowel causing intussusception with intestinal necrosis and perforation.
doi:10.1159/000326930
PMCID: PMC3078240  PMID: 21503167
Intestinal polyps; Polyps; Ileal neoplasm; Intussusception; Intestinal obstruction; Intestinal perforation; Immunohistochemistry
19.  Capsule impaction presenting as acute small bowel perforation: a case series 
Introduction
Perforation caused by capsule endoscopy impaction is extremely rare and, at present, only five cases of perforation from capsule endoscopy impaction are reported in the literature.
Case presentation
We report here two cases of patients with undiagnosed small bowel stenosis presenting with acute perforation after capsule endoscopy. Strictures in the small bowel were likely the inciting mechanism leading to acute small bowel obstruction and subsequent distension and perforation above the capsule in the area of maximal serosal tension.
Case 1 was a 55-year-old Italian woman who underwent capsule endoscopy because of recurrent postprandial cramping pain and iron deficiency anemia, in the setting of negative imaging studies including an abdominal ultrasound, upper endoscopy, colonoscopy and small bowel follow-through radiograph. She developed a symptomatic bowel obstruction approximately 36 hours after ingestion of the capsule. Emergent surgery was performed to remove the capsule, which was impacted at a stenosis due to a previously undiagnosed ileal adenocarcinoma, leading to perforation.
Case 2 was a 60-year-old Italian man with recurrent episodes of abdominal pain and diarrhea who underwent capsule endoscopy after conventional modalities, including comprehensive blood and stool studies, computed tomography, an abdominal ultrasound, upper endoscopy, colonoscopy, barium enema and small bowel follow-through, were not diagnostic. Our patient developed abdominal distension, acute periumbilical pain, fever and leukocytosis 20 hours after capsule ingestion. Emergent surgery was performed to remove the capsule, which was impacted at a previously undiagnosed ileal Crohn’s stricture, leading to perforation.
Conclusions
The present report shows that, although the risk of acute complication is very low, the patient should be informed of the risks involved in capsule endoscopy, including the need for emergency surgical exploration.
doi:10.1186/1752-1947-6-121
PMCID: PMC3424159  PMID: 22554208
20.  Delayed Rupture of Gallbladder Following Blunt Abdominal Trauma 
Mædica  2014;9(3):266-268.
A 29-year-old gentleman presented to surgery emergency with severe upper abdominal pain and vomiting. He reported to had been hit in his abdomen by a ball during a cricket match. Computerized tomogram of the abdomen revealed hematoma within the gallbladder lumen, laceration of segment six of liver, and hemoperitoneum. The patient did not agree for laparotomy advised to him, and so, managed conservatively. The patient reported back to us with high grade fever, jaundice, and painful abdominal distension after seven days of discharge from the hospital. His abdominal examination showed features of generalized peritonitis. Surgical abdominal exploration revealed a single perforation in the fundus of gallbladder with frozen calot'striangle. Subtotal cholecystectomy was done. Histopathology of excised gallbladder revealed xanthogranulomatous inflammation. The present case report highlights that early exploration and cholecystectomy should be considered in patients with gallbladder injury to obviate the risk of delayed perforation.
PMCID: PMC4305995
21.  Isolated Meckel’s diverticulum perforation as a sequel to blunt abdominal trauma: a case report 
Introduction
Meckel’s diverticulum is the commonest congenital abnormality of the gastrointestinal tract. Its infrequent occurrence is mirrored by the paucity of large series of data on it in the literature. Hemorrhage, obstruction and inflammation are the three main categories of complications resulting from Meckel’s diverticulum. Perforation of Meckel’s diverticulum following blunt abdominal injury is very rare indeed. We present what we believe to be the first case to be published from Africa.
Case presentation
A 29-year-old Nigerian Igbo man presented with progressively worsening abdominal pain following a road traffic accident. He was a front-seat passenger traveling without a seat belt. On physical examination his abdomen was distended with guarding and rigidity. A provisional diagnosis of peritonitis secondary to perforation of intestinal viscus was made. Our patient had an emergency laparotomy, where a perforated Meckel’s diverticulum was discovered. A segmental resection of his ileum and reanastomosis were done. He had postoperative surgical site infection, but was asymptomatic for three months of follow-up.
Conclusion
Perforation of Meckel’s diverticulum is rarely suspected as a cause of peritonitis following blunt abdominal injury. This case indicates the need to be aware of the possibility to limit morbidity associated with delayed management of such a perforation.
doi:10.1186/1752-1947-8-111
PMCID: PMC3992154  PMID: 24693872
Abdominal trauma; Meckel’s diverticulum; Perforation
22.  A Case of Liposarcoma With Peritonitis Due to Jejunal Perforation 
Sarcoma  2003;7(1):29-33.
A 21-year-old man, who had been treated for congenital dilatation of the bile duct 13 years previously, presented with an acute abdomen. The physical examination suggested peritonitis, and an emergent laparotomy was performed. A perforation was foundin the jejunum approximately 100 cm distal to the ligament of Treitz, followed by resection of a 60-cm jejunal segment. No tumorous lesions were found during the operation, and the resected jejunal segment showed only focal myxomatous thickening of the serosa. Despite intensive therapy, he died of uncontrollable septic shock 2 days after the operation. Unexpectedly, however, histological examination revealed a liposarcoma, showing an unclassifiable histology. From the distribution of the lesion and the histological findings, it is thought that a primary lesion was somewhere else, covered by severe adhesions due to the previous operation, and that the tumor cells spreading from it could have caused the jejunal perforation through vascular involvement. Although extremely rare, liposarcomas in the abdomen can cause intestinal perforation. It is important for both clinicians andpathologists to carefully investigate the cause of an unusual clinical presentation such as intestinal perforation.
doi:10.1080/1357714031000114183
PMCID: PMC2395510  PMID: 18521366
23.  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
24.  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
25.  Fecal Occult Blood Test for Colorectal Cancer Screening 
Executive Summary
The colorectal cancer (CRC) screening project was undertaken by the Medical Advisory Secretariat (MAS) in collaboration with the Cancer Care Ontario (CCO).
In November 2007, the Ontario Health Technology Advisory Committee (OHTAC) MAS to conduct an evidence-based analysis of the available data with respect to colorectal cancer diagnosis and prevention. The general purpose of the project was to investigate the effectiveness, cost effectiveness, and safety of the various methods and techniques used for colorectal cancer screening in average risk people, 50 years of age and older.
The options currently offered for colorectal cancer screening were reviewed and five technologies were selected for review:
Computed tomographic (CT) colonography
Magnetic resonance (MR) colonography
Wireless capsule endoscopy (PillCam Colon)
Fecal occult blood test (FOBT)
Flexible sigmoidoscopy
In this review, colonoscopy was considered as the “gold standard” technique by which the effectiveness of all other modalities could be evaluated. An economic analysis was also conducted to determine cost-effectiveness of different screening modalities.
Evidence-based analyses have been prepared for each of these technologies, as well as summary document that includes an economic analysis, all of which are presented at the MAS Web site: http://www.health.gov.on.ca/english/providers/program/mas/tech/techmn.html
Objective
The objective of this evidence review is to examine the effectiveness and cost-effectiveness of fecal occult blood testing (FOBT), including guaiac FOBT (gFOBT) and immunochemical FOBT (iFOBT), for use in colorectal cancer (CRC) screening in asymptomatic, average-risk adults.
Specifically:
Is the use of gFOBT or iFOBT associated with a reduction in CRC and overall mortality?
What are the sensitivity and specificity of gFOBT and iFOBT for the detection of 1) CRC and 2) large polyps (≥ 1 cm)?
Clinical Need
CRC is the most common cause of non-tobacco related cancer death in Canada. It has been estimated that in 2007, 7,800 people were diagnosed with CRC in Ontario and 3,250 died from the disease, making the province’s incidence and mortality rate of CRC amongst the highest in the world.
Description of Technology/Therapy
There are two general types of FOBT that are categorized according to the analyte detected: guaiac FOBT (gFOBT) and immunochemical FOBT (iFOBT). Blood in the stool is a nonspecific finding but may originate from CRC or larger (>1 cm) polyps (small adenomatous polyps do not tend to bleed). Bleeding from cancers and larger polyps may be intermittent and not always detectable in a single sample. The FOBT thus requires regular testing that consists of collecting specimens from consecutive bowel movements. A positive gFOBT or iFOBT involves a diagnostic workup with colonoscopy to examine the entire colon in order to rule out the presence of cancer or advanced neoplasia.
Methods of Evidence-Based Analysis
A literature search was conducted from January 2003 to June 2008 that included OVID MEDLINE, MEDLINE In-Process and Other Non-Indexed Citations, EMBASE, the Cumulative Index to Nursing & Allied Health Literature (CINAHL), The Cochrane Library, and the International Agency for Health Technology Assessment/Centre for Review and Dissemination.
Inclusion Criteria
Patients at average risk for CRC
All patients must be at least 50 years of age
Biennial FOBT as a screening modality and use of colonoscopy as the reference standard
Systematic reviews and randomized controlled trials (RCTs)
Outcomes: CRC mortality, overall mortality, sensitivity, specificity, adverse effects
Exclusion Criteria
Studies involving fewer than 100 patients
Studies that do not report sufficient data for analysis
Comparisons of Interest
Evidence exists for these comparisons of interest:
gFOBT compared with the reference “gold standard” colonoscopy (or double-contrast barium enema where colonoscopy is incomplete or contraindicated)
iFOBT compared with the reference gold standard colonoscopy (or DCBE where colonoscopy is incomplete or contraindicated)
gFOBT compared with iFOBT
The quality of the diagnostic studies was examined according to the ‘GRADE Working Group criteria’ for grading quality of evidence and strength of recommendations for diagnostic tests and strategies.
Summary of Findings
Single-Test Studies
There is limited direct/indirect evidence that iFOBT has sensitivity/specificity superior to that of unrehydrated gFOBT for CRC detection:
sensitivity for gFOBT:
pooled iFOBT sensitivity:
There is evidence that iFOBT and gFOBT have lower sensitivities for adenoma detection than for CRC detection:
sensitivity for rehydrated gFOBT
pooled iFOBT sensitivity
Repeated-Test Studies
No trials have examined CRC mortality outcomes after repeated testing of iFOBT.
Two RCTs from the United Kingdom and Denmark showed significant reduction in CRC mortality using unrehydrated gFOBT biennially
Relative risk reductions of 13% (UK trial) and 16% (Danish trial); absolute difference of 0.1% (UK trial) and 0.2% (Danish trial).
No significant reduction in overall mortality
Interval cancers (CRC that develop in the intervals between routine screening)
United Kingdom trial: 236 CRCs detected by positive test, 236 interval CRCs after negative test
Danish trial: 120 CRCs detected by positive test, 146 interval CRCs after negative test
Unrehydrated gFOBT has low sensitivity for CRC detection (45% in the UK trial and 54% in the Danish trial).
true positive rate
false positive rate
true negative rate
false negative rate
Guaiac FOBT – GRADE Quality of Evidence for Interventions
CRC indicates colorectal cancer; FOBT, fecal occult blood test; GRADE, Grading of Recommendations Assessment, Development and Evaluation; RCT, randomized controlled trial.
Unlikely to be an important uncertainty.
GRADE Quality of Evidence for Diagnostic Tests: Implications of Testing Focusing on Accuracy
Benefit from diagnosis and treatment after confirmatory colonoscopy
Small risk of bowel perforation during colonoscopy
Benefit of reassurance
Anxiety/worry leading up to confirmatory colonoscopy
Small risk of bowel perforation during confirmatory colonoscopy
Detriment from delayed diagnosis
Some uncertainty (until after confirmatory colonoscopy)
No Uncertainty
Uncertainty
Uncertainty
FOBT indicates fecal occult blood test; GRADE, Grading of Recommendations Assessment, Development and Evaluation.
Immunochemical FOBT – GRADE Quality of Evidence for Diagnostic Studies
FN indicates false negative; FOBT, fecal occult blood test; FP, false positive; Development and Evaluation; TN, true negative; TP, true positive.
Uncertainty until after confirmatory colonoscopy
Stress/worry for patient until confirmatory colonoscopy
Detrimental effects due to delayed diagnosis.
For these 3 reasons, downgrade quality from High to Moderate.
For these 3 reasons, downgrade quality from Moderate to Low.
Considerations for the Ontario Health System
Executive Summary Table 4 shows the potential system pressures and benefit/risk analysis for the use of FOBT and colonoscopy to screen for CRC in average-risk adults, ages 50 and over in Ontario.
Summary of Potential System Pressures for FOBT Screening
Prevent and detect
Detect
Every 10 years
Must repeat at regular intervals
Every 2 years
Must repeat at regular intervals
Observational studies
RCTs
Used as gold standard in studies
Intervention GRADE quality: High (gFOBT)
Diagnostic GRADE quality: Low (iFOBT)
No RCTs examining the effectiveness of repeated iFOBT on CRC mortality reduction were identified
Limited direct/indirect evidence that iFOBT has superior sensitivity/specificity to unrehydrated gFOBT for detection of CRC
0.1% risk of serious bleeding and perforation requiring surgery
0.3% risk of serious complications (stroke/bleeding requiring hospitalization/ myocardial infarction)
High interval cancer rate
The small benefit in CRC mortality reduction (absolute difference 0.1% to 0.2%) also coincides with a 0.3% risk of serious complications.
No food 1 day prior to exam
Office/hospital visit
Complete bowel preparation
Sedation
Eliminate citrus fruit and juices and vitamin C from diet for 3 days prior to/during stool collection.
Person applies 2 samples per bowel movement (each occurring on 3 different days) onto test areas of FOBT cards.
Increased demand for colonoscopies and colonoscopists or nurses who perform colonoscopies.
Patient receives kit from family physician, pharmacist
Patients mail completed FOBT kit to participating laboratory
Results sent back to patient
Increased demand for colonoscopies for positive patients
Removal of polyp during colonoscopy or surgery
Referral to colonoscopy
Cost-effective
Cost-effective
2nd of 5 choices in a patient survey study
5th of 5 choices in a patient survey study
FOBT indicates fecal occult blood test;; gFOBT, guaiac FOBT; GRADE, Grading of Recommendations Assessment, Development and Evaluation; iFOBT, immunochemical FOBT; RCT, randomized controlled trial.
PMCID: PMC3377532  PMID: 23074514

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