Does the large amount of ascites lateralize the inferior epigastric artery in liver cirrhosis?

OBJECTIVE: The most common cause of hemorrhage after paracentesis is direct needle puncture of the inferior epigastric artery (IEA). This study examined the relationship between the amount of the ascites and the location of the IEA in liver cirrhosis. METHODS: Abdominal computed tomography (CT) examinations of patients with liver cirrhosis were reviewed retrospectively and divided into two groups according to the amount of ascites. The distances between the midline and the IEAs of both sides were measured at the umbilicus, McBurney's point, anterior superior iliac spine, and mid-inguinal level. Branching of the IEAs, abdominal wall and mesenteric varices in the abdomen below the umbilicus level were recorded. RESULTS: A total of 120 abdominal CTs were reviewed. The distances from the midline to the IEA in the large ascites group were longer than those in the small ascites group at the level of the right McBurney's point (44.5±14.6 mm vs. 39.6±11.8 mm, P=0.043) and left McBurney's point (48.6±15.3 mm vs. 43.3±11.5 mm, P=0.035). The incidence of abdominal wall varices was higher in the large ascites group (21.7% vs. 5.0%, P=0.014). CONCLUSION: In patients with liver cirrhosis, the large amount of ascites might be associated with lateralizing the location of the IEA. Moreover, it may be necessary to confirm the blood vessels in the abdominal wall and mesentery near the puncture site by bedside ultrasound before the paracentesis.

Adverse Drug Reactions in Adult Patients Visiting an Emergency Department: Based on Spontaneous Reporting System

PURPOSE: Adverse drug reaction (ADR) is known to be a substantial reason for emergency departments (ED) visits. Additionally, it also is a frequent occurrence in ED. The aim of the study was to compare the characteristics between ADRs that occurred in ED and ADRs that occur elsewhere based on the spontaneous reporting system in a hospital. METHODS: In this retrospective observational study, the data was collected by the spontaneous ADR reporting system within an electronic medical record system during a 24-month period. ADR of patients aged more than 18 years were included in this study. RESULTS: Patients with ADR was older in ED (42.6±14.5 vs. 53.9±17.2, p<0.001) and they were administered with less medications (2.0±1.3 vs. 4.4±4.4, p<0.001). The proportion of ADR reported by doctors in ED was higher than that in non-ED (41.2% vs. 28.2%, p<0.001). The proportion of the severe ADR was not significantly different between the ED and non-ED groups (2.9% vs. 3.8%, p=0.701). The most common symptom of ADRs in ED and non-ED groups were cutaneous (52.9%) and gastrointestinal (42.2%), respectively; the most common implicated medication was analgesics (62.7%) and analgesics (41.5%), respectively. CONCLUSION: The characteristics of ADR in ED is different from that in non-ED locations. Further studies are needed to differentiate education and prevention strategies of ADR in ED from those in non-ED locations.

A Case of Acute Appendicitis of Children which its Symptoms and Signs were Self-disappeared

Acute appendicitis is a disease resulting from inflammation of the appendix. The most common symptoms and physical examinations are the following: right lower abdomen pain, tenderness, rebound tenderness, nausea, vomiting, and fever. The clinician makes a diagnosis based on these symptoms and physicals along with ultrasonography or radiologic imaging, such as computed tomography (CT), forviewing of the inflamed appendix. In this case a seven-year-old-male visited the Emergency Room with abdominal pain and tendernessin in the right lower quadrant, whose symptoms disappeared spontaneously without treatment, although the bedside ultrasonography showed an inflamed appendix. The patient underwent surgery and the operation findings indicated a concordant diagnosis. We report this case as the cardinal symptom of acute appendicitis has been right lower quadrant pain for many years, which may lead to misdiagnosis.

Prospective Evaluation of the Pediatric Appendicitis Score with Right Lower Quadrant Abdominal Pain Registry

PURPOSE: Acute appendicitis is one of the most common surgical emergencies in the emergency department (ED) and various scoring systems such as the Alvarado score or the pediatric appendicitis score (PAS) have been developed to aid diagnosis. This study was designed to evaluate the diagnostic value of PAS in South Korea children, prospectively. METHODS: All patients visiting our ED with right lower quadrant (RLQ) abdominal pain or RLQ tenderness were enrolled in our registry. Patients under age of 18, whose guardian agreed with the informed consent were included in this study. Those who were diagnosed at previous hospitals were excluded. Appendicitis was confirmed by operative and histopathological findings. A follow up call was made to verify final outcome within 14 days. RESULTS: We collected data on 1648 patients and a total of 512 patients participated in the study. The mean age was 11.9 years. Seventy four patients (14.5%) had pathology-proven appendicitis and negative appendectomy was performed in three patients (3.9%). Statistical analysis showed that with PAS > or =4, sensitivity 70.1%, specificity 60.4%, and area under curve (AUC) 0.708. With the Alvarado score > or =5, sensitivity 72.7%, specificity 67.2%, and AUC 0.748. CONCLUSION: Usefulness of PAS in diagnosis of pediatric acute appendicitis is limited. PAS showed no significant superiority over the Alvarado score. Therefore, it seems reasonable to use both scores for evaluation of pediatric acute appendicitis in South Korea.

A Point of Care Ultrasound During Catheterization of Internal Jugular Vein; Sonographic Assessment of the Venous Excavation (SAVE) Protocol

PURPOSE: Central venous catheterization (CVC) plays important roles in treatment of critically ill patients. Although use of ultrasound has led to a decrease in CVC related complications, adverse events still occur. Therefore, we usually check the chest x-ray for confirmation. The purpose of this study was to evaluate the usefulness of point of care ultrasound during catheterization of the internal jugular vein (IJV). METHODS: The authors conducted a prospective study of emergency department (ED) patients undergoing CVC via IJV. Among the enrolled patients, 97 underwent SAVE, which consisted of 1) pre-CVC lung ultrasound, 2) ultrasound guided puncture of central vein, 3) sonographic detection of the guide wire before dilation, and 4) post-CVC lung ultrasonography. The primary outcome was the success rate of each stage. The secondary outcome was an estimated time of the SAVE exam. The entire process of patients' care was recorded by video for the purpose of time analysis. Physicians described anatomical site, reason for catheterization, and acute mechanical complications. RESULTS: In all subjects, the guide wire was visible within the lumen of the IJV. Median access time, from insertion to detection of the guide wire in IJV via ultrasound, was 20 seconds. After the CVC was inserted, post-CVC lung ultrasonography was completed within a median time of 68 seconds. Identification of the chest x-ray image took more than 5 minutes. Acute mechanical complications - which occurred in three patients - were detected immediately by SAVE. CONCLUSION: SAVE may provide greater safety during CVC by detection of CVC related complication more properly, without delay.

A Case of Spontaneous Hemo-pneumothorax

Spontaneous hemo-pneumothorax, a hemothorax that occurs without trauma, is a very rare condition; however, as a result of excessive bleeding, it can be lethal. Also, if the bleeding is scanty, the physician might recognize hemothorax in case of performing invasive procedures, such as chest tube insertion, and may misunder stand as a complication of the procedure. For this reason, acknowledgement of the spontaneous hemo-pneumothorax in the emergency department is very important. We report on a case of a spontaneous hemo-pneumothorax in a healthy 18-year-old male presenting with chest pain who developed a spontaneous pneumothorax with a profuse amount of hemothorax.