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1.  Actinomycosis of the sigmoid colon: A case report 
Abdominal actinomycosis is a chronic suppurative infection caused by Actinomyces species. The ileo-cecal region is most commonly affected, while the left side of the colon is more rarely involved. The infection has a tendency to infiltrate adjacent tissues and is therefore rarely confined to a single organ. Presentation may vary from non specific symptoms and signs to an acute abdomen. A computed tomography scan is helpful in identifying the inflammatory process and the organs involved. It also allows visual guidance for percutaneous drainage of abscesses, thus aiding diagnosis. Culture is difficult because of the anaerobic character and slow growth of actinomycetes. Colonoscopy is usually normal, but may shows signs of external compression. Preoperative diagnosis is rare and is established only in less than 10% of cases. In uncomplicated disease, high dose antibiotic therapy is the mainstay of treatment. Surgery is often performed because of a difficulty in diagnosis. Surgery and antibiotics are required in the case of complicated disease. Combined medical and surgical treatment achieves a cure in about 90% of cases. The authors report a case of sigmoid actinomycosis where diagnosis was made from the histology, and a review of the literature is presented.
PMCID: PMC2999117  PMID: 21160798
Abdominal pain; Actinomycosis; Gram-positive bacteria; Sigmoid colon; Sulfur
2.  Actinomycosis of Cecum Associated with Entamoeba Infection Mimicking Perforated Colon Cancer 
Actinomycosis is a granulomatous disease caused by Actinomyces that mimics other intra-abdominal pathologies especially neoplasms. Correct diagnosis can be rarely established before radical surgery. On the other hand Entamoeba infection affects a considerable number of people worldwide. To our knowledge only one case has been reported to be affected by both organisms. We report a man who has been operated for a mass in the cecum mimicking a perforated colon cancer. Abdominal CT revealed a mass with features of an invading neoplasm. After radical surgery, definitive pathology revealed that the mass was due to actinomycosis associated with Entamoeba infection. The postoperative period was uneventful and the patient was on long-course antibiotherapy. It is important to consider actinomycosis especially in patients with intra-abdominal masses with unusual aggressiveness to prevent unnecessary surgery. However, surgery can be unavoidable especially in the presence of complicated disease or high index of suspicion for malignancy.
PMCID: PMC3657401  PMID: 23738157
3.  Abdominal Actinomycosis Associated with a Sigmoid Colon Perforation in a Patient with a Ventriculoperitoneal Shunt 
Yonsei Medical Journal  2006;47(4):583-586.
Abdominal actinomycosis causing hydronephrosis in a patient with a ventriculoperitoneal shunt is very rare. A 27-year-old female patient was admitted complaining of lower abdominal pain. She had undergone ventriculoperitoneal shunt surgery 10 years ago. Abdominal Ultrasonography and a CT scan demonstrated an inflammatory mass in the lower left quadrant of the abdomen causing obstructive hydroureter and hydronephrosis. Laparotomy revealed a diffusely infiltrating mass involving the small bowel, mesentery, and sigmoid colon, and a 1 cm perforation in the sigmoid colon. Actinomycosis was diagnosed upon histological examination. After treatment with antibiotics and surgery, the patient's condition improved.
PMCID: PMC2687743  PMID: 16941752
Actinomycosis; hydronephrosis; ventriculoperitoneal shunt
4.  Left-sided omental torsion with inguinal hernia 
We report a case of surgically proved left-sided torsion of the greater omentum that caused secondary by untreated inguinal hernia. Case A 36-year-old man presented to our hospital with abdominal pain. He had been diagnosed with a left inguinal hernia, but he had not received any treatments. Contrast-enhanced computed tomography (CT) of the abdomen showed a large fat density mass below the Sigmoid colon and left inguinal hernia with incarcerated fat. Exploratory laparotomy revealed torsion of the greater omentum with small bloody ascites. The greater omentum was twisted into one and a half circles and entered into a left inguinal hernia. An omentectomy with a repair of left inguinal hernia was performed. A resected omentum was submitted for pathological examination, which showed hemorrhagic infarction. Omental torsion is a rare cause of acute abdominal pain but should be included in the differential diagnoses of acute abdomen, especially in patients with untreated inguinal hernia.
PMCID: PMC4066108  PMID: 16489689
Omental torsion; Acute abdomen; Inguinal hernia
5.  Actinomycosis in urachal remnants: A rare cause of pseudotumor 
Actinomycosis is a chronic inflammatory condition caused by Actinomyces israeli, a gram positive anaerobic bacterium. It can have a variety of clinical manifestations and can mimic a malignancy. We present one such case of urachal actinomycosis that mimicked a tumor. A 28-year-old man presented with abdominal pain of 20 days duration. Per abdominal palpation revealed a firm mass with ill-defined borders in the suprapubic region. Computed tomography and magnetic resonance imaging scans of the pelvis showed an irregular lesion in the urinary bladder extending to the umbilicus, giving the impression of urachal remnants with inflammation. Peroperatively, an irregular, hard mass measuring 6 × 5 cm, involving the anterior and posterior bladder walls, the appendix, the terminal ileum and sigmoid colon, was seen, which was suspicious for a malignancy. Frozen sections from the mass showed extensive inflammation and a florid fibroblastic proliferation, giving the impression of an inflammatory pseudotumor. The tissue was extensively sampled for paraffin sections and only one of them revealed a colony of Gram, PAS and GMS- positive organisms, conclusive for Actinomycosis. It is important to be aware of this uncommon, yet significant, presentation of a common infectious disease in order to avoid misdiagnosis and over-treatment as a malignancy.
PMCID: PMC3263229  PMID: 22279327
Actinomycosis; pseudotumor; urachal remnants
6.  Isolated hepatic actinomycosis: a case report 
Actinomyces are slow growing, non-spore forming, gram-positive, branching bacilli that thrive in anaerobic and microareophilic conditions. Actinomyces are more commonly associated with oral and cervicofacial infections. Hepatic involvement in infections of the abdomen (known as isolated hepatic actinomycosis) is rare, accounting for only 5% of all cases of actinomycosis.
Case presentation
We present the case of a 75-year-old Caucasian woman with a 3-month history of night sweats, fever, chills, abdominal bloating, anorexia, weight-loss, and early satiety. The patient was found to have isolated hepatic actinomycosis infection after undergoing a laparotomy with a biopsy of the liver. The patient has now recovered.
Isolated hepatic actinomycosis is a rare and often overlooked etiology for a liver mass. Given its subacute presentation and nondescript symptomatology, physicians should be aware of this differential and the potential pitfalls in diagnosis and management.
PMCID: PMC2833155  PMID: 20181118
7.  Abdominal-Pelvic Actinomycosis Mimicking Malignant Neoplasm 
Abdominal-pelvic actinomycosis is often mistaken for other conditions, presenting a preoperative diagnostic challenge. In a 46-year-old female, computed tomography showed an abdominal-pelvic retroperitoneal mass extending from the lower pole of the right kidney to the lower pelvis. The patient had a 3-year history of intrauterine device. The mass appeared to involve the ascending colon, cecum, distal ileum, right Fallopian tube and ovary, and ureter anteriorly and the psoas muscle posteriorly. The resection of retroperitoneal mass, distal ileum appendicectomy, right hemicolectomy, and right salpingo-oophorectomy was performed. The postoperative period was uneventful. Penicillin therapy was given for six months without any complication. The retroperitoneal mass measured 4.5 × 3.5 × 3 cm, surrounded adjacent organs and histologically showed inflammatory granulomatous tissue, agglomeration of filaments, and sulfur granules of Actinomyces, with positive reaction with periodic acid Schiff. Right tubo-ovarian abscess was present. Abdominalpelvic actinomycosis should always be considered in patients with a pelvic mass especially in ones using intrauterine device.
PMCID: PMC3163399  PMID: 21904441
8.  Urachal Actinomycosis Mimicking a Urachal Tumor 
Korean Journal of Urology  2010;51(6):438-440.
A 26-year-old man presented with lower abdominal discomfort and a palpable mass in the right lower quadrant. An abdominal computed tomography (CT) scan revealed an abdominal wall mass that extended from the dome of the bladder. Fluorine-18 fluorodeoxyglucose (FDG) positron-emission tomography/CT (PET/CT) showed hypermetabolic wall thickening around the bladder dome area that extended to the abdominal wall and hypermetabolic mesenteric infiltration. Differential diagnosis included a urachal tumor with invasion into adjacent organs and chronic inflammatory disease. Partial cystectomy with abdominal wall mass excision was performed, and the final pathologic report was consistent with urachal actinomycosis.
PMCID: PMC2890064  PMID: 20577614
Actinomycosis; Positron-emission tomography; Urachal cyst
9.  Pelvic actinomycosis presenting as a malignant pelvic mass: a case report 
Pelvic actinomycosis constitutes 3% of all human actinomycosis infections. It is usually insidious, and is often mistaken for other conditions such as diverticulitis, abscesses, inflammatory bowel disease and malignant tumors, presenting a diagnostic challenge pre-operatively; it is identified post-operatively in most cases. Here we present a case that presented as pelvic malignancy and was diagnosed as pelvic actinomycosis post-operatively.
Case presentation
A 48-year-old Caucasian Turkish woman presented to our clinic with a three-month history of abdominal pain, weight loss and difficulty in defecation. She had used an intra-uterine device for 16 years, however it had recently been removed. The rectosigmoidoscopy revealed narrowing of the lumen at 12 cm due to a mass lesion either in the wall or due to an extrinsic lesion that prevented the passage of the endoscope. On examination, there was no gynecological pathology. Magnetic resonance imaging showed a mass, measuring 5.5 × 4 cm attached to the rectum posterior to the uterus. The ureter on that side was dilated. Surgically there was a pelvic mass adhered to the rectum and uterine adnexes, measuring 10 × 12 cm. It originated from uterine adnexes, particularly ones from the left side and formed a conglomerated mass with the uterus and nearby organs; the left ureter was also dilated due to the pelvic mass. Because of concomitant tubal abscess formation and difficulty in dissection planes, total abdominal hysterectomy and bilateral salphingo-oophorectomy was performed (our patient was 48 years old and had completed her childbearing period). The cytology revealed inflammatory cells with aggregates of Actinomyces. Penicillin therapy was given for six months without any complication.
Pelvic actinomycosis should always be considered in patients with a pelvic mass especially in ones using intra-uterine devices, and who have a history of appendectomy, tonsillectomy or dental infection. Surgeons should be aware of this infection in order to avoid excessive surgical procedures.
PMCID: PMC3039605  PMID: 21272333
10.  Abdominopelvic actinomycosis: spectrum of imaging findings and common mimickers 
Acta Radiologica Short Reports  2014;3(2):2047981614524570.
Actinomycosis is a rare suppurative disease that may mimic other inflammatory conditions on imaging. Its invasive nature may lead to mass formation and atypical presentation thus making accurate diagnosis quite difficult.
To describe the different aspects of abdominopelvic actinomycosis on cross-sectional imaging and indicate discriminative findings from other inflammatory or neoplastic diseases.
Material and Methods
In our study we analyzed 18 patients (15 women, 3 men; age range, 25–75 years; mean age, 50 years) with pathologically proved abdominopelvic actinomycosis. Contrast-enhanced abdominal computed tomography (CT) had been performed in all patients. Eleven patients had a history of using intrauterine contraceptive devices. Bowel site, wall thickness and enhancement degree, inflammatory infiltration, and features of peritoneal or pelvic mass were evaluated at CT.
The sigmoid colon was most commonly involved. Most patients showed concentric bowel wall-thickening, enhancing homogenously and inflammatory infiltration of pericolonic fat was mostly diffuse. In 11 patients, one or more pelvic abscesses were revealed, while a peritoneal or pelvic mass adjacent to the involved bowel segment was seen in three cases. Infiltration into the abdominal wall was seen in three cases while in one case there was thoracic dissemination.
Actinomycosis is related not only to long-term use of intrauterine contraceptive devices and should be included in the differential diagnosis when cross-sectional imaging studies show concentric bowel wall-thickening, intense contrast enhancement, regional pelvic or peritoneal masses, and extensive inflammatory fat infiltration with abscess formation.
PMCID: PMC4001438  PMID: 24778807
Pelvis; actinomycosis; abscess; computed tomography (CT)
11.  Extensive colonic stricture due to pelvic actinomycosis. 
Journal of Korean Medical Science  1995;10(2):142-146.
A 36-year-old woman presented with a palpable tender mass at the left lower quadrant of the abdomen. She had suffered from constipation for five years and had a previous history of intrauterine device-use for one year. Preoperative barium enema and abdominopelvic CT showed a compatible finding of rectosigmoid colon cancer or left ovary cancer. She underwent segmental resection of the sigmoid colon along with the removal of left distal ureter, left ovary and salpinx. Pathologic examination revealed actinomycotic abscesses containing sulfur granules. Thereafter, she took parenteral ampicillin (50mg/kg/day) for one month and oral amoxicillin (250mg, tid) for 2 months consecutively. The patient has no specific problems for 6 months after surgical resection and long-term antibiotic therapy. This report may be the first of intrauterine device-associated pelvic actinomycosis involving both sigmoid colon and rectum extensively.
PMCID: PMC3054142  PMID: 7576294
12.  Penetrated sigmoid colon by air gun pellet could be life threatening: A case report 
Air and paintball guns have been in existence for over 400 year. Although serious injury or death can result from the use of such guns, previous literature has not mentioned the issue of the penetration of the sigmoid colon by an air gun pellet.
We report a rare case of a 44-year-old Caucasian woman referred to abdominal surgery after an accidental small wound had occurred in the lower left abdominal quadrant that was caused by an air gun pellet. The blood and biochemical analyses were normal but the CT scan revealed the presence of a foreign body – an air gun pellet in the left iliac region of the abdomen. Clinically, during the initial 24 h significant changes were not noticed. After 42 h, however, pain and local tenderness in the lower left abdominal quadrant was expressed. A laparotomy revealed a retained pellet in the wall of the sigmoid colon and a small leak with colonic content with consecutive local peritonitis also occurred. The foreign body was removed and the opening edges in the colon were excised and closed with the primary suture.
The hollow organs of the digestive tract, albeit very rarely penetrated by an air gun pellet, do not typically show all signs of an acute abdomen in the early posttraumatic phase. Such injuries can lead to a pronounced infection, which may cause septic shock if not appropriately treated.
For correct diagnosis, a careful approach and several daily clinical observations are required.
PMCID: PMC4275851  PMID: 25437671
Air gun pellet; Sigmoid colon perforation; Peritonitis
13.  Actinomycosis of the colon with invasion of the abdominal wall: An uncommon presentation of a colonic tumour 
Actinomycosis is an uncommon chronic suppurative infectious disease that is caused by Actinomycetes organisms, which are gram-positive, microaerophilic, anaerobic bacteria. The most common type causing disease in humans is Actinomyces israelii. This organism is a commensal of the human mouth and is seldom pathogenic. When it does cause disease, however, three main clinical types of involvement are recognized including cervico-facial, thoracic and abdominal actinomycosis.
Herein, we present the case of a 79-year-old male patient who underwent surgical exploration following presentation with abdominal pain and an abdominal mass, initially thought to be a malignancy. Pathologic examination confirmed this as a case of abdominal actinomycosis. This diagnosis should always be included in the differential diagnosis of patients who present with an infiltrative abdominal mass.
PMCID: PMC3199683  PMID: 22096664
Abdominal; Actinomycosis; Abdominal mass; Abscess; Colonic tumour
14.  Abdominal actinomycosis with multiple myeloma: A case report 
Oncology Letters  2014;8(4):1876-1878.
Actinomycosis is a chronic suppurative infection, for which immune suppression is a predisposing factor. In unusual cases, this disease may present as an abdominal wall involvement simulating a soft tissue tumor as seen in the present case. The presented patient had no signs of trauma or surgical approach and the pathology was considered to be a primary abdominal wall actinomycosis. Preoperative diagnosis is difficult due to the nonspecific nature of clinical presentation, radiographic and laboratory findings. Surgery combined with antibiotic treatment is a curative approach for this relatively rare infection. Surgeons must be aware of this disease in order to ensure correct diagnosis and to prevent performing any unnecessary procedures. The present study describes a case of abdominal actinomycosis with multiple myeloma, together with a review of important points related to this disease.
PMCID: PMC4156177  PMID: 25202429
actinomycosis; multiple myeloma; immune-suppression
15.  Internal abdominal hernia: Intestinal obstruction due to trans-mesenteric hernia containing transverse colon 
Internal abdominal hernias are infrequent but an increasing cause of bowel obstruction still often underdiagnosed. Among adults its usual causes are congenital anomalies of intestinal rotation, postsurgical iatrogenic, trauma or infection diseases.
We report the case of a 63-year-old woman with history of chronic constipation. The patient was hospitalized for two days with acute abdominal pain, abdominal distension and inability to eliminate flatus. The X-ray and abdominal computerized tomography scan (CT scan) showed signs of intestinal obstruction. Exploratory laparotomy performed revealed a trans-mesenteric hernia containing part of the transverse colon. The intestine was viable and resection was not necessary. Only the hernia was repaired.
Internal trans-mesenteric hernia constitutes a rare type of internal abdominal hernia, corresponding from 0.2 to 0.9% of bowel obstructions. This type carries a high risk of strangulation and even small hernias can be fatal. This complication is specially related to trans-mesenteric hernias as it tends to volvulize.
Unfortunately, the clinical diagnosis is rather difficult.
Trans-mesenteric internal abdominal hernia may be asymptomatic for many years because of its nonspecific symptoms. The role of imaging test is relevant but still does not avoid the necessity of exploratory surgery when clinical features are uncertain.
PMCID: PMC4064401  PMID: 24880799
Hernia; Abdominal surgery; Intestinal obstruction/sigmoid mesocolon; Internal abdominal hernia; Transmesenteric hernia; Radiology
16.  Early intervention in intersigmoid hernia may prevent bowel resection—A case report 
Intersigmoid hernia is a rare internal hernia presenting with symptoms of bowel obstruction. Preoperative diagnosis is uncommon but computerised tomography (CT) may show signs to suggest internal hernia.
A 63-year-old female presented with abdominal pain, vomiting and absolute constipation. Examination revealed a tense distended abdomen. A plain abdominal radiograph showed features of small bowel obstruction. Conservative management was initiated without success and a CT scan was performed which showed a dilated distal oesophagus, stomach and small bowel with a non-dilated length of distal ileum and large bowel. Internal hernia was suggested as a possible cause and the patient underwent a laparotomy where a loop of small bowel was found to be strangulated and gangrenous within the intersigmoid fossa. The gangrenous bowel was resected, an end-to-end anastamosis was performed and the fossa was closed. The patient made an uneventful recovery.
Hernias of the sigmoid mesocolon account for 6% of internal hernias with internal hernias themselves causing between 0.2 and 4.1% of intestinal obstruction. This report presents a case of intersigmoid hernia, a rare internal hernia which should be suspected in patients presenting with acute obstruction, no past surgical history and no external hernia. Patients with these symptoms should receive an urgent CT scan to facilitate early surgery and minimise strangulation and prevent bowel resection.
Intersigmoid hernia presents with acute obstruction, no past surgical history and no external hernia. Urgent CT scanning and early surgery may minimise strangulation, conserve bowel and reduce patient morbidity and mortality.
PMCID: PMC3215259  PMID: 22096754
Intersigmoid hernia; Intersigmoid fossa; Sigmoid mesocolon hernia; Internal hernia; Intestinal obstruction
17.  A case report of incisional hernia through a 5 mm lateral port site following laparoscopic cholecystectomy 
Less than 10 mm port-site herniation is a rare complication after laparoscopic surgery. We report a case of complicated herniation through the 5-mm lateral trocar port site.
A 63-year old obese female was admitted due to intestinal obstruction. She has undergone the laparoscopic cholecystectomy 1 year ago. On examination, abdomen was bloated and roughly 10 cm size mass was palpable on the right subcostal area. Plane radiogram of the abdomen showed signs of intestinal obstruction. Since conservative treatment was ineffective, the patient was operated on. The laparotomy revealed a protrusion of a part of right large intestine and greater omentum into the subcutaneous space through the abdominal wall defect below right subcostal margin. There was a dilatation of intestines proximally incarcerated colon. It was released and a part of omentum was resected. The peritoneum and fascia-muscular defect was closed by interrupted vicryl sutures.
Acute herniation through a 5 mm size most lateral trocar port site is a rare complication of laparoscopic surgery requiring prompt differential diagnosis.
PMCID: PMC3193761  PMID: 22022103
Bowel obstruction; Cholecystectomy; Laparoscopy; Lateral 5 mm port; Port-site hernia
18.  Omental whirl associated with bilateral inguinal hernia: a case report 
Torsion of the omentum is a rare cause of abdominal pain. It is clinically similar to common causes of acute surgical abdomen and is often diagnosed during surgery. Inguinal hernia is a common condition but not frequently related with torsion of the omentum.
Case presentation
A 40-year-old Caucasian man came to our emergency department with abdominal pain of the left quadrant and abdominal distension for 2 days. His medical history included an untreated left inguinal hernia in the last year. Computed tomography revealed densification of mesocolon with left omentum “whirl” component and other signs of omental torsion. During an exploratory laparoscopy, a wide twist of his omentum with necrotic alterations that extended to the bilateral inguinal hernial content was observed. Omentectomy and surgical repair of bilateral inguinal hernia were performed.
Torsion of the omentum is a rare entity and usually presents a diagnostic challenge. The use of abdominal computed tomography can help diagnosing torsion of the omentum preoperatively and, thus, prevents a surgical approach. Nonetheless, some cases of torsion of the omentum require surgical repair. Accordingly, a laparoscopic approach is minimally invasive and efficient in performing omentectomy.
PMCID: PMC4090653  PMID: 24985935
Abdominal pain; Omentum; Torsion; Whirl sign
19.  Mesenteric panniculitis of the sigmoid colon: a case report and review of the literature 
Mesenteric panniculitis of the sigmoid colon is a rare occurrence in surgical practice. The aim of this article is to present a case of mesenteric panniculitis of the sigmoid colon and a short review of the literature.
Case presentation
We reviewed the hospital record of a 63-year-old man who presented with a palpable mass in the left abdomen and clinical signs of a partial bowel obstruction. The pre-operative impression was a possible cancer of the sigmoid colon. A laparotomy was performed through a midline incision. The mesentery was found to be markedly thickened, constricted and puckered. The normal architecture of the adipose tissue had been lost and replaced with an irregular nodular mass. The microscopic pathologic sections demonstrated a chronic reactive inflammatory process with an exuberant proliferation of fibroblasts and fibrocytes. The adipose tissue contained scattered areas of steatonecrosis with foci of lipid-laden macrophages, lymphocytes and plasma cells. The sigmoid colon and its mesocolon were resected. The postoperative course was uneventful and the patient was discharged in good condition, and followed up for the next two years.
Mesenteric panniculitis of sigmoid is an extremely rare entity of unknown origin in which the normal architecture of the mesentery is replaced by fibrosis, necrosis and calcification. On gross examination the alterations may be mistaken for a neoplastic process. A frozen section may be necessary for confirmation of the diagnosis. When the advanced inflammatory changes became irreversible and bowel obstruction occurs, resection may be indicated.
PMCID: PMC2092431  PMID: 17910751
20.  A Suspicious Pancreatic Mass in Chronic Pancreatitis: Pancreatic Actinomycosis 
Introduction. Pancreatic actinomycosis is a chronic infection of the pancreas caused by the suppurative Gram-positive bacterium Actinomyces. It has mostly been described in patients following repeated main pancreatic duct stenting in the context of chronic pancreatitis or following pancreatic surgery. This type of pancreatitis is often erroneously interpreted as pancreatic malignancy due to the specific invasive characteristics of Actinomyces. Case. A 64-year-old male with a history of chronic pancreatitis and repeated main pancreatic duct stenting presented with weight loss, fever, night sweats, and abdominal pain. CT imaging revealed a mass in the pancreatic tail, invading the surrounding tissue and resulting in splenic vein thrombosis. Resectable pancreatic cancer was suspected, and pancreatic tail resection was performed. Postoperative findings revealed pancreatic actinomycosis instead of neoplasia. Conclusion. Pancreatic actinomycosis is a rare type of infectious pancreatitis that should be included in the differential diagnosis when a pancreatic mass is discovered in a patient with chronic pancreatitis and prior main pancreatic duct stenting. Our case emphasizes the importance of pursuing a histomorphological confirmation.
PMCID: PMC4332457
21.  Incarcerated spontaneous transdiaphragmatic intercostal hernia 
Prolapse of abdominal viscera into the thoracic subcutis through the chest wall is known as transdiaphragmatic intercostal hernia (TIH). Herein, we present the first case of spontaneous TIH presenting as a thoracoabdominal emergency.
Presentation of case
A 78-year-old male presented with acute left thoracoabdominal pain following a sudden bulge at the left posterolateral chest wall corresponding to a partially reducible soft tissue mass with ecchymosis at the overlying skin. Paroxysmal cough during the last four days was also reported along with a prolonged daily application of a special tight abdominal belt that used while milking sheep. CT-scan of the abdomen showed intrathoracic proptosis of the splenic flexure through a defect of the left hemidiaphragm and subcutaneous prolapse of the herniated colon through the 7th intercostal space. On laparotomy, the herniated colon showed signs of ischemic necrosis leading to segmental colectomy followed by repair of the diaphragmatic defect.
The clinical diagnosis of spontaneous TIH demands very high index of suspicion and thorough patient's history. In this case the daily elevation of the intraabdominal pressure due to an abdominal milking belt might have caused gradual slimming and loosening of the diaphragm and the intercostals muscles rendering them vulnerable to sudden increases of the thoracoabdominal pressure due to violent coughing. Such a hypothesis is reasonable in the absence of traumatic injury in this patient.
Spontaneous TIH should be suspected in patients presenting with a sudden palpable chest wall bulge and associated thoracoabdominal symptoms in the absence of preceding injury.
PMCID: PMC3199691  PMID: 22096730
Incarcerated; Transdiaphragmatic intercostal hernia; Pleuroperitoneal hernia
22.  Strangulated inguinal hernia presenting as haemoperitoneum 
BMJ Case Reports  2012;2012:bcr0320125962.
A 57-year-old man presented with abdominal pain following a collapse, with peritonism in his lower abdomen. He was haemodynamically stable, with haemoglobin of 12.6 g/dl. His significant medical history included open bilateral inguinal hernia repairs. CT demonstrated fluid within the abdominal cavity, and an area of stranding lying medially within the left iliac fossa. Ultra-sound guided fluid aspiration demonstrated frank blood. During admission, the patient noted a recurrence of his left inguinal hernia. Laparotomy revealed haemoperitoneum, and a haematoma arising in the left iliac fossa, walled off by mesentery of the sigmoid colon and adherent omentum. The open repair of the recurrent inguinal hernia identified the sac contents to be similar to the omentum. This association implies the omentum had herniated within the inguinal canal, tore or avulsed, resulting in haemorrhage from the proximal omental blood vessel resulting in haemoperitonism.
PMCID: PMC3448753  PMID: 22962376
23.  Peritonitis secondary to traumatic duodenal laceration in the presence of a large pancreatic pseudocyst: a case report 
A pancreatic pseudocyst is a common sequela of severe acute pancreatitis. Commonly, it presents with abdominal pain and a mass in the epigastrium several weeks after the acute episode and can be managed conservatively, endoscopically or surgically. We report a patient with a pancreatic pseudocyst awaiting endoscopic therapy who developed a life-threatening complication following a rather innocuous trauma to the abdomen.
Case presentation
A 23-year-old Asian male student presented as an emergency with an acute abdomen a week after a minor trauma to his upper abdomen. The injury occurred when he was innocently punched in the abdomen by a friend. He experienced only moderate discomfort briefly at the time. His past medical history included coeliac disease and an admission four months previously with severe acute pancreatitis. He was hospitalized for 15 days; his pancreatitis was thought to be due to alcohol binge drinking on weekends. Ultrasound scanning showed no evidence of gallstone disease. Five days after the trauma, he became anorexic, lethargic and feverish and started vomiting bilious content. Seven days post-trauma, he presented to our emergency department with severe abdominal pain. An emergency laparotomy was performed where a transverse linear duodenal laceration was found at the junction of the first and second part of his duodenum, with generalized peritonitis. His stomach and duodenum were stretched over a large pancreatic pseudocyst posterior to his stomach. It was postulated that an incomplete duodenal injury (possibly a serosal tear) occurred following the initial minor trauma, which was followed by local tissue necrosis at the injury site resulting in a delayed presentation of generalized peritonitis.
This is the first reported case of a traumatic duodenal laceration following minor blunt trauma in the presence of a large pancreatic pseudocyst. Minor blunt abdominal trauma in a normal healthy adult would not be expected to result in a significant duodenal injury. In the presence of a large pseudocyst, however, the stretching of the duodenum over the pseudocyst had probably predisposed the duodenum to this injury. Patients awaiting therapeutic interventions for their pancreatic pseudocysts should be warned about this unusual but life-threatening risk following minor blunt abdominal trauma.
PMCID: PMC3215995  PMID: 22029762
24.  Delayed ischemic gangrene change of distal limb despite optimal decompressed colostomy constructed in obstructed sigmoid colon cancer: A case report 
Creating blow-hole colostomy for decompression could provide a time-saving and efficient surgical procedure for a severely debilitated case with a completely obstructed colorectal cancer. Complications are reported as prolapse, retraction, and paracolostomal abscess. However, complication with an ischemic distal limb has not been reported. We report a case of critical intra-abdominal disease after decompressed colostomy for relieving malignant sigmoid colon obstruction; a potential fatal condition should be alerted. A 76-year-old male visited our emergency department for symptoms related to obstructed sigmoid colon tumor with foul-odor vomitus containing fecal-like materials. An emergent blow-hole colostomy proximal to an obstructed sigmoid lesion was created, and resolution of complete colon obstruction was pursued. Unfortunately, extensive abdominal painful distention with board-like abdomen and sudden onset of high fever with leukocytopenia developed subsequently. Such surgical abdomen rendered a secondary laparotomy with resection of the sigmoid tumor along with an ischemic colon segment located proximally up to the previously created colostomy. Eventually, the patient had an uneventful postoperative hospital stay. In the present article, we have described an emergent condition of sudden onset of distal limb ischemia after blow-hole colostomy and concluded that despite the decompressed colostomy would resolve acute malignant colon obstruction efficiently; impending ischemic bowel may progress with a possible irreversible peritonitis. Any patient, who undergoes a decompressed colostomy without resection of the obstructed lesion, should be monitored with leukocyte count and abdominal condition survey frequently.
PMCID: PMC4066174  PMID: 16521237
Colorectal cancer obstruction; Colostomy; Ischemic colitis; Laparotomy
25.  Duplication Cyst of the Sigmoid Colon 
A 21-year-old male with developmental delay presented with abdominal pain of two days' duration. He was afebrile and his abdomen was soft with mild diffuse tenderness. There were no peritoneal signs. Plain x-ray demonstrated a large air-filled structure in the right upper quadrant. Computed tomography of the abdomen revealed a 9 × 8 cm structure adjacent to the hepatic flexure containing an air-fluid level. It did not contain oral contrast and had no apparent communication with the colon. At operation, the cystic lesion was identified as a duplication cyst of the sigmoid colon that was adherent to the right upper quadrant. The cyst was excised with a segment of the sigmoid colon and a stapled colo-colostomy was performed. Recovery was uneventful. Final pathology was consistent with a duplication cyst of the sigmoid colon. The cyst was attached to the colon but did not communicate with the lumen.
PMCID: PMC2821771  PMID: 20169095

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