Efficiency of unenhanced MRI in the diagnosis of acute appendicitis: comparison with Alvarado scoring system and histopathological results.

PURPOSE: The purpose of this study was to assess the diagnostic value of unenhanced magnetic resonance imaging (MRI) in the diagnosis of acute appendicitis and compare with Alvarado scores and histopathological results. MATERIALS AND METHODS: The study included 85 consecutive patients (mean age, 26.5±11.3 years) who were clinically suspected of having acute appendicitis. Each patients Alvarado scores were recorded and unenhanced MRI was performed, consisting of T1-weighted, T2-weighted and fat-suppressed T2-weighted fast spin-echo sequences. The MR images were prospectively reviewed in consensus for the presence of acute appendicitis by two radiologists who were blinded to the results of the Alvarado scores. The study population were divided into three subgroups based on the MRI findings: Group I: definitely not appendicitis, Group II: probably appendicitis, Group III: definitely appendicitis. All patients were divided into two subgroups according to Alvarado scores as Group A (low: 1-6), and Group B (high: 7-10). MR findings were compared with Alvarado scores and histopathological findings. RESULTS: Sixty-six (77.6%) of the 85 patients with clinically suspected acute appendicitis, had undergone surgery. The diagnosis of appendicitis could be correctly achieved with MRI in 55 (83.3%) of 57 (86.4%) patients with histopathologically proven acute appendicitis. The sensitivity, specificity, positive predictive value and negative predictive value of MRI examination and Alvarado scoring system in the diagnosis of acute appendicitis were 96.49%, 66.67%, 94.83%, 75.0% and 84.21%, 66.67%, 94.12%, 40.0%, respectively. CONCLUSIONS: MRI is a valuable technique for detecting acute appendicitis even in the cases with low Alvarado scores. To increase the diagnostic accuracy and preventing unnecessary laparotomies for suspected appendicitis, shorter and cheaper unenhanced basic MRI may be performed.

Case report: acute pancreatitis caused by postcholecystectomic hemobilia.

BACKGROUND: Hemobilia is a rare cause of upper GI bleeding and the reasons for the majority of the cases are iatrogenic. It is also one of the rarest vascular complication following laparoscopic cholecystectomy but acute pancreatitis due to postcholecystectomic hemobilia as a late complication of cholecystectomy is not yet described. CASE PRESENTATION: We presented the case of a 32-year-old female, admitted to our emergency surgery clinic with hematemesis, jaundice and abdominal pain who had a history of laparoscopic cholecystectomy 4 months ago. Patient was diagnosed as acute pancreatitis and obstructive jaundice caused by postcholecystectomic hemobilia. Afterwards she is successfully treated by ERCP, angiographic identification and embolization of right hepatic artery pseudoaneurysm. CONCLUSIONS: We presented that postcholecystectomic hemobilia may cause acute pancreatitis and acute pancreatitis caused by postcholecystectomic hemobilia should also be included to the rare complications which may occur following cholecystectomy.

The role of ERCP in the management of bile leakage: endoscopic sphincterotomy versus biliary stenting.

INTRODUCTION: Bile leakage is a common complication of cholecystectomy. The aim of this study was to compare endoscopic sphincterotomy (EST) and biliary stenting (BS) in the treatment of bile leaks after cholecystectomy. PATIENTS AND METHODS: Twenty-seven patients with bile leakage following cholecystectomy underwent endoscopic retrograde cholangiography (ERCP). Patients were randomized into two groups (EST and BS +/- EST), according to the initial therapeutic endoscopic intervention. The patients were allocated into subgroups once more, according to diameter of the common bile duct (CBD). Outcomes and efficacy of BS and EST on fistula closure and the time to fistula closure were investigated. RESULTS: The median time between cholecystectomy and ERCP in the EST and BS groups was 6.45 +/- 3.41 and 4.50 +/- 1.99 days, respectively. The mean daily amount of biliary leakage in the EST and BS groups was 376.92 +/- 243.77 and 441.07 +/- 216.08 cc/day, respectively. The diameter of the distal part of CBD in the EST and BS groups was 9.07 +/- 3.84 and 8.28 +/- 4.04 mm, respectively. Mean fistula closure was achieved in 6.45 +/- 3.41 in 11 of 13 patients in the EST group and 4.50 +/- 1.99 days in the BS group in all patients. However, mean time of closure was significantly shorter in the BS 4.71 +/- 2.14 group, compared to EST (9.67 +/- 2.51), among patients with distal CBD diameter (< or =8 mm). CONCLUSIONS: BS seems to be a more effective method than EST in the management of postcholecystectomy among patients with bile leakage and without CBD dilatation. BS might be the first-line treatment among such patients. However, further prospective, randomized, clinical trials regarding CBD dilatation are warranted.

Acute biliary pancreatitis related with pregnancy: a 5-year single center experience.

BACKGROUND: Pregnancy-associated acute biliary pancreatitis is a rare but challenging clinical entity in terms of diagnosis and management. We report our institutional medical data of pregnancy-associated acute biliary pancreatitis. METHODS: Medical records of 27 patients admitted to our clinics for pregnancy-associated acute biliary pancreatitis between January 2005 and January 2010 were reviewed. RESULTS: Of the 27 patients, 25 (93%) were in the post-partum period, and 2 (7%) were pregnant. Seventeen patients (63%) were managed with conservative treatment, and were scheduled for interval cholecystectomy, while 10 patients (37%) had early cholecystectomy prior to discharge. The mortality rate was 3% (n=1). CONCLUSION: Pregnancy-associated acute biliary pancreatitis usually has a mild-to-moderate clinical course with a favorable outcome, and can be managed successfully with conservative treatment. Early cholecystectomy done prior to discharge in the initial admission should be considered in mild-to-moderate pregnancy-associated acute biliary pancreatitis, except in patients within the first trimester.

Wandering spleen: Report of two cases.

Wandering spleen is a rare clinical condition which presents with a variety of symptoms with abdominal pain, abdominal mass, and acute abdomen. It may also remain silent until diagnosed by a routine imaging study. Treatment options may differ depending on the presenting clinical picture. Herein we present two cases of wandering spleen treated by splenectomy, with one of them admitted to our emergency clinic with torsion.

Comparison of operative and non operative management of acute appendicitis.

BACKGROUND: In this prospective study, operative and nonoperative management of acute appendicitis were evaluated regarding their safety and cost effectiveness. METHODS: Two hundred ninety patients presenting to our Emergency Department between March 2005 and March 2006 with acute appendicitis were included in this prospective study. Nonoperative medical therapy was performed in 107 patients (Group 1), and 183 patients were treated surgically (Group 2). Routine follow-up controls were done on the 10th day, at the 3rd and 6th months and at the first year after discharge in Group 1. Both groups were compared regarding age, gender, mean hospital stay, modified Alvarado score, morbidity, mortality, and cost effectiveness. RESULTS: The male/female ratio of Groups 1 and 2 were 65/42 (mean age: 30.98+/-1.30) and 125/58 (mean age: 26.25+/-0.79), respectively. In Group 1, 19 patients were operated. Operation indications were resistance to therapy, patient's request, and operation in another hospital. Although the mean hospital stay of Group 1 was statistically significantly longer than Group 2, the mean cost of the therapy was $559 in Group 2 and $433 in Group 1. Morbidity rates were similar, with no mortality in either group. CONCLUSION: With its high success rate and cost effectiveness, medical treatment seems to be a good alternative to the gold standard therapy of surgery in management of acute appendicitis.

Is endoscopic band ligation superior to injection therapy for Dieulafoy lesion?

BACKGROUND: Dieulafoy lesion is a rare but serious cause of gastrointestinal system bleeding. An aberrant submucosal artery, which was described in 1884, causes the bleeding. The lesion can be located anywhere in the gastrointestinal tract but is most commonly found in the proximal stomach up to 6 cm from the gastroesophageal junction. Increased experience in endoscopy has led to an increased frequency of its proper diagnosis. Various methods are used to achieve successful hemostasis by endoscopy in Dieulafoy lesion; however, comparative studies about the success rates of these methods are still needed. In this study, we compared two of these endoscopic hemostatic methods: band ligation, and injection therapy in Dieulafoy lesions. METHODS: In this prospective study, 18 patients admitted to the Emergency Surgical Unit between January 2002 and December 2005 with upper gastrointestinal bleeding diagnosed as Dieulafoy lesion were included. Diagnose of Dieulafoy lesion was made at initial or second-look endoscopy. Patients were randomized in two groups according to therapy method: injection therapy and band ligation groups. Therapy was applied immediately after recognizing the lesion at the same endoscopic procedure. Two groups were compared regarding demographical data, presence of comorbid diseases, history of medication and previous gastrointestinal system bleeding, hemodynamic status, laboratory values, need for transfusion, endoscopic findings, success rate of the treatment method, mean hospital stay, complications, and recurrence of bleeding. RESULTS: Of 588 patients admitted with upper gastrointestinal hemorrhage, Dieulafoy lesion was recognized in 18 cases (3.1%) at initial or second-look endoscopy. All patients were men with a mean age of 62.8 (range, 30-80) years. Band ligation was applied to ten patients and the remaining eight were treated by injection therapy. During the follow-up period, rebleeding occurred in six of the patients (75%) with injection therapy, whereas no rebleeding occurred for the patients in the band ligation group. The rebleeding rate and mean hospital stay was significantly higher for the injection therapy group. CONCLUSIONS: Our study suggests that of the endoscopic treatment methods, band ligation is superior to injection therapy for the treatment Dieulafoy lesions.

Primary omental hydatid cyst.

Hydatid disease is still a frequently seen disease in endemic area like South America, Middle Asia and South Europe as well as Turkey. Although the disease occurs more frequently in liver and lungs, it can be seen in any part of the body. In this report we present a case of isolated omental hydatid disease which is a rare entity in the English literature.

Endoscopic transcolonic catheter-free pelvic abscess drainage.

Natural orifice transluminal endoscopic surgery is a novel therapeutic method in development that uses different routes of surgical approach. The use of various methods, instruments and accessories during this procedure are currently being investigated. A case of appendicitis-related intra-abdominal abscess that was resolved by a transcolonic endoscopic approach using a wide-channel colonoscope with the help of precut and standard sphincterotome without radiological percutaneous drainage is presented.

Rectus sheath hematoma: three case reports.

INTRODUCTION: Rectus sheath hematoma is an uncommon cause of acute abdominal pain. It is an accumulation of blood in the sheath of the rectus abdominis, secondary to rupture of an epigastric vessel or muscle tear. It could occur spontaneously or after trauma. They are usually located infraumblically and often misdiagnosed as acute abdomen, inflammatory diseases or tumours of the abdomen. CASE PRESENTATION: We reported three cases of rectus sheath hematoma presenting with a mass in the abdomen and diagnosed by computerized tomography. The patients recovered uneventfully after bed rest, intravenous fluid replacement, blood transfusion and analgesic treatment. CONCLUSION: Rectus sheath hematoma is a rarely seen pathology often misdiagnosed as acute abdomen that may lead to unnecessary laparotomies. Computerized tomography must be chosen for definitive diagnosis since ultrasonography is subject to error due to misinterpretation of the images. Main therapy is conservative management.

Albendazole is not effective for primary treatment of hepatic hydatid cysts.

INTRODUCTION: In current practice, minimal invazive interventions such as percutaneous drainage and laparoscopic surgery in adjunct treatment with benzimidazoles have been gaining acceptance in treatment of hydatid cystic disease with minimal morbidity and mortality. In this prospective study, the efficacy and validity of primary medical therapy in the treatment of hydatid cystic disease has been investigated. PATIENTS AND METHODS: Sixty-five patients with hepatic cystic disease were treated with albendazole alone between January 2004 and June 2007. All of the patients were administrated albendazole as 10 mg kg(-1) day(-1) divided into two equal doses for 6 months with ultrasonography (USG), serological tests, full-blood cell count and hepatic function tests performed in 2 months intervals in the course of treatment. RESULTS: Fifty of the patients were female and 15 were male with a mean age of 47.0+/-16.9 (17-80). A total number of 106 cysts were present in 65 patients. Mean cystic diameter was 5.5+/-3.6 (1-16). In 41 of the patients, cysts were solitary and in remaining 24 patients cysts were multiple. Mean follow-up period was 28.3+/-8.6 (12-42) months. The overall success rate of albendazole therapy was 18% (12/65) in the study. CONCLUSION: Albendazole therapy for hepatic hydatidosis is not effective in the vast majority of patients and, therefore, should not be used as the primary therapy for patients who are surgical candidates.

Short-term effects of gallbladder perforations during laparoscopic cholecystectomy on respiratory mechanics and depth of pain.

BACKGROUND: In this study the effects of gallbladder perforations during laparoscopic cholecystectomy on respiratory mechanics and depth of pain in the postoperative period was evaluated. METHODS: Between April 2004 and February 2006 we planned to perform 179 laparoscopic cholecystectomies. One hundred of these patients were included in this study. Patients were divided into two groups: group 1 with gallbladder perforation during the operation and group 2 without perforation. Two groups were compared regarding age, gender, comorbidities, mean hospital stay, respiratory function tests, and postoperative pain scores. RESULTS: Gallbladder perforation occurred in 33 patients (33%). The male-to-female ratio of group I was 5/28. In group 2 the male-to-female ratio was 12/55. Age and perforation had a significant correlation according to Spearman's correlation test (p < 0.05, r = 0.211). Regarding respiratory function tests and arterial blood gases analysis, there was a significant decrease in both groups postoperatively but perforation had no effect on them. No statistically significant difference occurred regarding mean hospital stay and postoperative visual pain scores (p > 0.05). CONCLUSION: Gallbladder perforation during laparoscopic cholecystectomy had no effect on postoperative respiratory mechanics and depth of pain.

Migrated endoclip and stone formation after cholecystectomy: a new danger of acute pancreatitis.

Endoclip migration into the common bile duct following laparoscopic cholecystectomy (LC) is an extremely rare complication. Migrated endoclip into the common bile duct can cause obstruction, serve as a nidus for stone formation, and cause cholangitis. We report a case of obstructive jaundice and acute biliary pancreatitis due to choledocholithiasis caused by a migrated endoclip 6 mo after LC. The patient underwent early endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy and stone extraction.

Combined treatment of iatrogenic rectourethral fistula with endoscopic fibrin glue application and clipping.

Rectourethral fistula (RUF) formation is a rare complication of prostatic surgery and other pelvic surgical procedures. The results of operations to correct RUF are not always satisfying, with a particular risk of recurrent breakdown or stricture formation at the site of the urethral closure. We present a case of a small RUF treated videoendoscopically with fibrin-glue application combined with endoscopic clipping.