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Diagnostic imaging
Published in Professor Sir Norman Williams, Professor P. Ronan O’Connell, Professor Andrew W. McCaskie, Bailey & Love's Short Practice of Surgery, 2018
Professor Sir Norman Williams, Professor P. Ronan O’Connell, Professor Andrew W. McCaskie
The erect chest x-ray (CXR) is the ideal first test for hollow organ perforation and as little as 10-20 mL of free air can be detected under the diaphragm, with the following caveats (Figures14.37and14.38): about 10 minutes should be left between sitting the patient upright to allow air time to rise; the free air must be sought under the right hemidiaphragm to prevent misinterpretation of the gastric air bubble; and the reviewer must be able to recognise Chilaiditi’s syndrome, the harmless and asymptomatic interposition of large bowel between the liver and diaphragm. Caution must also be exercised in interpreting any free air in the context of recent abdominal surgery, as air can persist for up to 5-7 days in the peritoneal cavity.
Case 52: Coffee Ground Vomiting
Published in Layne Kerry, Janice Rymer, 100 Diagnostic Dilemmas in Clinical Medicine, 2017
An erect chest x-ray should be requested, to evaluate whether there is a pneumonia present, but also to look for evidence of free air under the diaphragm (signifying abdominal organ perforation) or mediastinal air indicative of oesophageal rupture.
Pediatric abdominal trauma
Published in David E. Wesson, Bindi Naik-Mathuria, Pediatric Trauma, 2017
Lauren Gillory, Bindi Naik-Mathuria
Pediatric abdominal trauma has become a largely nonoperative endeavor, but there are certainly situations where surgical intervention is warranted. Indications for operation include intra-abdominal injury with persistent hemodynamic instability despite aggressive resuscitation, pneumoperitoneum, or clinical evidence of hollow organ perforation, and a penetrating mechanism with peritoneal violation. Laparotomy is the gold standard for evaluation, but it carries a high morbidity and occasional mortality, as well as a life-long risk for adhesive intestinal obstruction [116]. Laparoscopy is a diagnostic and therapeutic alternative to laparotomy in hemodynamically stable pediatric abdominal trauma cases [117, 118]. Laparoscopy can provide vital information that may prevent unnecessary laparotomy. In addition, some injuries may be addressed with laparoscopy with a resultant reduction in morbidity.
Perforation of the excluded segment without pneumoperitoneum following Roux-en-Y gastric bypass surgery: case report and literature review
Published in Acta Chirurgica Belgica, 2021
Maxime Peetermans, Jana Vellemans, Guido Jutten, Pieter D’hooge, Peter Delvaux, Frederik Huysentruyt, Anneleen Van Hootegem, Jos Callens, Olivier Peetermans
Diagnosis and treatment in RYGB patients is challenging, since their altered anatomy hinders diagnostic and therapeutic interventions. Conventional signs of hollow organ perforation, such as pneumoperitoneum and extravasation of orally administered contrast, are often absent. The absence of a pneumoperitoneum can be explained by the lack of free air in the excluded stomach. When reviewing the literature, a pneumoperitoneum was established in 12 of 48 patients [10,12,14,16,19,20,22–24,28–30], half of whom were patients with a duodenal perforation [10,12,14,16,19,20]. In most of these cases, pneumoperitoneum was only revealed on abdominal CT. Only in three patients, pneumoperitoneum was demonstrated on abdominal radiography [10,29,30]. In one patient the perforation was accompanied by a gastrogastric fistula, which evidently leads to free abdominal air [16]. Extravasation of orally administered contrast is also absent since it does not reach the perforated excluded segment. However, after percutaneously introducing contrast in the excluded stomach, Charuzi et al. [10] were able to demonstrate extravasation of contrast on abdominal radiography. Ultrasound and/or CT scan are useful for investigating such patients and will also contribute to the identification of other causes of acute right upper quadrant pain. As in the case we present, free peritoneal fluid is often the only abnormality that can be identified on CT scan.
A 10-year cohort study of 175 primary gastrointestinal lymphoma cases in Thailand: clinical features and outcomes in the immunochemotherapy era
Published in Hematology, 2021
Weerapat Owattanapanich, Theera Ruchutrakool, Tawatchai Pongpruttipan, Monthira Maneerattanaporn
The 175 PGIL patients enrolled had a median age was 60 years (range, 20–98) and a male predominance (60%). The PS of the patients, which were based on the Eastern Cooperative Oncology Group (ECOG) classification system, were ECOG-PS 0, 0.6%; 1, 47.4%; 2, 41.1%; 3, 9.7%; and 4, 0.6%. Most of the patients (82.8%) had abdominal pain as a presenting symptom. Other common initial manifestations were palpable abdominal mass (29.3%), upper GI bleeding (20.1%), lower GI bleeding (12.1%), gut obstruction (10.9%), hollow viscus organ perforation (10.4%), chronic diarrhea (10.4%), superficial lymphadenopathy (8%), and dysphagia (7%). Over half of the patients presented with B symptoms, of which 50.6% were significant weight loss, 12.6% were fever, and 2.9% were night sweats (Table 1). Because there were various lymphoma subtypes, we re-evaluated the staging of all cases based on the Ann Arbor staging system. The staging 0, 1, 2, 3, 4 were 30.9%, 20.0%, 10.3% and 29.7%, respectively.
Management of patients with septic shock due to Candida infection
Published in Hospital Practice, 2018
Matteo Bassetti, Antonio Vena, Alessandro Russo
The prevalence of fungal infection among patients with septic shock is usually lower than that observed for bacterial infections; however, recent epidemiological data showed an increased role of Candida spp. An American multicenter study showed a significant increase in the incidence of sepsis accounted for 4.6% of all infections, ranging from 82.7 in 1979 to 240.4 cases per 100,000 population in 2000. While bacterial causes of sepsis grew with the general increase, fungal etiology raised more rapidly with a 200% increase [21]. Similar data have been extrapolated analyzing other large studies. In the ADRENAL study [22], among 3658 randomized patients, 1241 of them showed positive cultures from different sample with Candida isolated in 38 (3%). Comparable results were also observed in the proMISe trial in which the incidence of fungal sepsis was 3% [23]. The incidence of Candida infection was even higher in the ABDOMIX study enrolling 243 patients with septic shock after surgery related to organ perforation [24]. Of the 217 cases with microbiological documentation, 39 of them (17.9%) had a fungal infection.