Traumatic abdominal wall hernia. Case report

Despite the high incidence of abdominal traumas, traumatic abdominal wall hernias (TAWHs) remain rare probably because of elasticity of the abdominal wall. The TAWH is due to blunt abdominal trauma with disruption of the abdominal wall muscles and fascia with intact overlying skin. TAWH can be classified into high energy injures (generally motor vehicle accidents) and low energy injures (impact on a small blunt object). Common example of the latter type is a fall onto a bicycle handlebar. The mechanism of the trauma includes sudden increase of intra-abdominal pressure and extensive shear forces applied to the abdominal wall. The diagnosis of TAWH is difficult in the Emergency Room because during the primary diagnostic process most attention is directed toward the detection of internal injures and TAWH can be missed. In this article we report a case of TAWH caused by a work accident (an heavy steel tube fallen onto the abdominal wall of the patient from a height of five meters) with delayed diagnosis.

Diagnosis of intra-abdominal injuries can be challenging in multitrauma patients with associated injuries. Our experience and review of the literature

ntroduction. Trauma is the most common cause of death and disability among patients during the first four decades of life. Abdominal trauma is reported to be the 3rd most common injured region. Clinical examination may be unreliable in the evaluation of these patients especially in the presence of associated injuries. Therefore the use of diagnostic tools is essential in the management of the injured patient with abdominal trauma and additional injuries. Patients and Methods. During 1 year period from December 2010 to November 2011 we recorded the patients that presented to the emergency department of our hospital and were found to suffer from intra-abdominal injuries. These patients were divided in two groups depending on whether they had additional comorbid injuries or not. Several parameters were recorded and compared between the two groups, such as mechanism of injury, general status and hemodynamic stability of the patient on presentation, physical examination, use of imaging modalities and concomitant findings, need for surgical intervention and mortality rates. Furthermore the discrepancy between physical findings and final diagnosis after the use of diagnostic adjuncts is reported. Results. We recorded 31 patients with abdominal trauma. 13 (42%) patients were found to suffer from abdominal trauma and associated injuries (Group I), whereas 18 (58%) presented with abdominal trauma alone (Group II). The patients of the first group presented hemodynamic instability in 38% of cases while the patients of the second in 22% of cases. Reduced consciousness was present in 38% in group I versus 17% in group II. Signs of abdominal injury during clinical examination were present in only 15% in group I versus 72% in group II that represented a remarkable difference between the two groups. Conservative treatment was possible in 15% of patients with additional injuries and in 22% of patients with abdominal injury alone. In group I there were two deaths whereas in group II all patients survived. Conclusion. In patients with abdominal trauma, associated injuries seem to add to the severity of injury and indicate a worse prognosis. Clinical examination is unreliable and misleading in the majority of these patients and the use of diagnostic tools cannot be overemphasized.

Spontaneous rupture of a giant hepatic hemangioma. Sequential treatment with preoperative transcatheter arterial embolization and conservative hepatectomy

Hemangioma is the most common benign tumor of the liver and it is often asymptomatic. Spontaneous rupture of liver hemangiomas is a rare but potentially lethal complication. Emergent hepatic resection has been the treatment of choice but carries high operative morbidity and mortality. Recently, preoperative transcatheter arterial embolization (TAE) has been used successfully for the management of bleeding ruptured liver tumors and non-operative treatment of symptomatic giant liver hemangiomas. We report a case of spontaneous rupture of a giant hepatic hemangioma that presented with thoracic and abdominal pain and shock due to hemoperitoneum. Once proper diagnosis was made the patient was successfully managed by TAE, followed by conservative hepatic resection.

Simultaneous Meckel’s diverticulitis and appendicitis: a rare complication in puerperium

We report a case of a 24-year-old woman who was delivered via cesarean section at 39 weeks and presented in the puerperium with symptoms of worsening abdominal pain and septicaemia. Preoperative ultrasonography suggested the presence of a pelvic collection. Explorative laparotomy revealed the simultaneous presence of Meckel's diverticulitis and appendicitis without bowel perforation. The patient made an uneventful recovery following small bowel resection with end to end reanastomosis and appendicectomy.

Multicystic nephroma in an elderly man. Case report

Multicystic nephroma is a relatively rare tumor of the kidney presenting unclear histological origin. Abdominal mass is a common onset sign in children while abdominal flank pain or abdominal discomfort, hematuria and recurrent urinary tract infections usually affect adults. Preoperative diagnosis is impossible especially in the adult variant of the tumor where clear cells carcinoma with cystic degeneration must always be suspected. We herein report a case of a 77 year old man complaining of flank abdominal pain and recurrent episodes of urinary tract infection due to a right-sided multicystic nephroma successfully treated with nephrectomy.

Small bowel mesentery solitary fibrous tumor. A rare neoplasia in a young male

Extrapleural Solitary Fibrous Tumors (SFT), in particular small bowel mesentery SFTs, are extremely rare neoplasms. We describe the case of a young male hospitalized for unspecific abdominal symptoms and evidence of a well-circumscribed mass arising from the small bowel mesentery. Histopathological and immunohistochemical analysis on the surgical specimen confirmed the diagnosis of SFT. A Pubmed search revealed only another case of small bowel mesentery SFT, confirming the extremely rarity of this tumor.

A case of extraovarian primary peritoneal carcinoma in an oophorectomized-hysterectomized patient: a diagnostic dilemma

Extra Ovarian Primary Peritoneal Carcinoma (EOPPC) is a rare type of adenocarcinoma of the pelvic and abdominal peritoneum. The objective examination and the histological aspect of the neoplasia virtually overlaps with that of ovarian carcinoma. The reported case is that of a 72 year-old patient who had undergone a total hysterectomy with bilateral annessiectomy surgery 20 years earlier subsequently to a diagnosis for uterine leiomyomatosis. The patient came to our attention presenting recurring abdominal pain, constipation, weight loss, severe asthenia and fever. Her blood test results showed hypochromic microcytic anemia and a remarkable increase CA125 marker levels. Instrumental diagnostics with Ultrasound (US) and CT scans indicated the presence of a single peritoneal mass (10-12 cm diameter) close to the great epiploon. The patient was operated through a midline abdominal incision and the mass was removed with the great omentum. No primary tumor was found anywhere else in the abdomen and in the pelvis. The operation lasted approximately 50 minutes. The post-operative course was normal and the patient was discharged four days later. The histological exam of the neoplasia, supported by immunohistochemical analysis, showed a significant positivity for CA 125, vimentin and cytocheratin, presence of psammoma bodies, and cytoarchitectural pattern resembling that of a serous ovarian carcinoma even in absence of primitiveness, leading to a final diagnosis of EOPPC. The patient later underwent six cycles of chemotherapy with paclitaxel (135 mg/m2/24 hr) in association with cisplatin (75mg/m2). At the fourth year follow-up no sign of relapse was observed. .

HIV Infection Presenting as Haemophagocytic Syndrome

The authors describe a case of a 48-year-old man who presented with four weeks of fever, generalized malaise, weight loss, right upper quadrant abdominal pain and hepatosplenomegaly. He evolved with pancytopenia, bone marrow haemophagocytosis and hyperferritinaemia. Recent diagnosis of HIV infection, with the exclusion of other plausible causes, prompted the diagnosis of haemophagocytic syndrome (HPS) secondary to HIV. Despite intensive care support and initiation of antiretroviral therapy, the patient died. HPS diagnosis secondary to HIV alone demands the exclusion of all the other secondary causes. The best approach includes early diagnosis and specific treatment of the associated cause, whenever possible.

Severe Case of Thrombotic Microangiopathy with a Delayed Diagnosis of Atypical Haemolytic Uraemic Syndrome Successfully Managed with Eculizumab

Objectives: To describe the diagnosis and treatment of a severely ill patient presenting with thrombotic microangiopathy (TMA) of unknown cause. Case presentation: An adult female presented to intensive care with abdominal pain and haemorrhagic shock, requiring reanimation. Results: Features of TMA were present, but initial plasma exchange was ineffective. Treatment with the anti-C5 antibody, eculizumab, improved laboratory parameters and organ function, albeit slowly. Eculizumab remains effective and well tolerated after 30 months of treatment. Conclusion: This case demonstrates the complexities and importance of early identification of atypical haemolytic uraemic syndrome in patients presenting with TMA.

Acute Acalculous Cholecystitis as a Presenting Manifestation in Systemic Lupus Erythematosus

Systemic lupus erythematosus (SLE) is known to involve the gastrointestinal tract, but gallbladder involvement is rare. The authors report the case of a 26-year-old postpartum female who presented with acute right upper quadrant abdominal pain and was diagnosed with acute acalculous cholecystitis (AAC). In the presence of concomitant features of nephritis, pericardial effusion, anaemia and positive ANA titre, the diagnosis of SLE was confirmed during hospitalisation. Histopathological analysis of the gall bladder revealed evidence of vasculitis. Although rare, AAC can be the first presentation of patients diagnosed with SLE. Prompt diagnosis and management results in a better patient outcome.