Splenic Artery Aneurysm Management in the Cirrhotic Patient Listed for Liver Transplantation: A Systematic Review.

BACKGROUND: Splenic artery aneurysms (SAA), although rare in the general population, occur more commonly in liver transplant candidates owing to cirrhosis-induced portal hypertension. In this population, particularly in the perioperative period, SAAs are at heightened risks of rupture with potentially fatal consequences. There is no consensus regarding optimal management of asymptomatic SAA diagnosed before liver transplantation. MATERIALS AND METHODS: We performed a systematic review of the literature to investigate the management options and outcomes of asymptomatic SAAs in liver transplant candidates. The EMBASE and MEDLINE electronic databases were used to identify articles. RESULTS: Eleven articles met the criteria for analysis and included 159 patients with SAAs, among whom 121 had asymptomatic aneurysms diagnosed pre transplant and subsequently underwent liver transplantation. The majority of SAAs were located distally or intrahilar (80%) and more than half of the patients had multiple SAAs. In 121 patients diagnosed pre transplant, 37 patients had treatment instigated (28 treated surgically and 8 treated radiologically). Post-transplant rupture was noted in 2 patients treated surgically (2/28) with no fatality. No rupture was observed in the radiologically treated group, although 1 patient died of splenic abscess and sepsis after embolization. In 86 untreated patients, 4 cases of post-transplant rupture were recorded (2/4 resulted in fatality). CONCLUSION: Asymptomatic SAAs are at risks of rupture post transplant and treatment should be considered, regardless of aneurysm size. Both surgical and radiological treatments offer adequate control, and choice of treatment is dependent on location and number of SAA present.

Pelvic abscess masquerading as urachal malignancy-a rare presentation of retained appendicolith.

Dropped or retained appendicoliths are uncommon complication of laparoscopic appendicectomies, and rarely they have been reported to cause complications such as pelvic abscesses or enterocutaneous fistulas. We reported on a rare presentation of a pelvic abscess masquerading as urachal malignancy in a 41-year-old male, 2 years after his laparoscopic appendicectomy. As urachal malignancy could not be unequivocally excluded on imaging findings alone, en bloc resection of this mass and partial cystectomy were performed. Histopathology study revealed pelvic abscess with no evidence of malignancy and a central calcification which corresponded to a faecolith identified on pre-appendicectomy imaging. We contributed this rare presentation to the limited existing literature about complications of retained appendicoliths. As laparoscopic appendicectomies are performed commonly as the standard of care of appendicitis, care should be taken to extract appendicoliths completely to prevent complications.

Conservative Management of Suspected Emphysematous Gastritis.

Emphysematous gastritis is a rare surgical condition. Although there is a lack of a common definition, the key features of its presentation include gastric emphysema on imaging and the presence of gas-forming organisms in the gastric mucosa. In this study, we report the case of an 80-year-old Caucasian male who presented with abdominal pain; a computed tomography scan demonstrated gastric emphysema (intra-mural air within the stomach). After upper gastrointestinal endoscopy excluded gross perforation, ulcer, and malignancy, the patient recovered to baseline with conservative management consisting of gastric rest (nil by mouth and nasogastric tube decompression), intravenous antibiotics, and intravenous proton pump inhibitor. Given the wide pathogenic mechanisms for gastric emphysema, we recommend a conservative but cautious approach if the patient does not demonstrate clinical features of hemodynamic instability, sepsis, and peritonitis.

Closed loop large bowel obstruction due to appendiceal signet cell carcinoma.

Signet cell carcinoma of the appendix is the rarest and the most aggressive subtype of appendiceal malignancy, typically presenting with non-specific symptoms. We describe a case of a 62-year-old male with large bowel obstruction, with computed tomography demonstrating dilated large bowels from caecum to proximal sigmoid colon and pneumoperitoneum. Intraoperatively, closed loop obstruction caused by dense adherence of sigmoid colon to caecum was noted, which had resulted in caecal perforation. Histopathology study indicated primary appendiceal malignancy of signet cell morphology with intraperitoneal spread to sigmoid colon. Large bowel obstruction from appendiceal malignancy has rarely been reported and similar presentations have not been described in the existing literature. When left-sided large bowel obstruction is suspected to be caused by a malignant stricture, it is essential to consider transperitoneal spread of appendiceal malignancy as potential aetiology, particularly in the elderly.

Bladder perforation: an unusual complication caused by rectus sheath haematoma.

Rectus sheath haematoma (RSH) is an uncommon cause of abdominal pain. Despite being previously viewed as a benign, self-limiting condition, there is increasing evidence suggesting significant local and systemic complications with RSH. We present a case of an 82-year-old female who developed a large RSH following prescription of therapeutic anticoagulation for her new onset atrial fibrillation. She subsequently developed significant haemodynamic collapse, which necessitated emergency radiological intervention. We describe a novel approach to prevent recurrence of bleeding by inserting a covered endovascular stent across the origin of inferior epigastric artery. We also describe a rare finding of bladder perforation, presumed secondary to pressure necrosis from the haematoma. Our report contributes to the growing evidence which suggests RSH, particularly secondary to anticoagulation in the elderly, can result in catastrophic complications. In addition, bladder perforation is a rare but possible complication that needs to be considered.