Non-perforated Stercoral Colitis patients with septic shock have a higher mortality than their perforated counterparts. A case report and review of literature.

INTRODUCTION AND IMPORTANCE: Stercoral colitis is an inflammatory condition caused by fecal impaction; it involves the colonic or rectal wall. It occurs most commonly in nursing home patients, chronic opioid users, and patients with mental impairment. CASE PRESENTATION: We present the case of a 36-year-old, obese, African American male with a history of intellectual disability, bipolar disorder, and chronic constipation. Patient presented to the emergency room after an episode of syncope, confusion, 24-hour abdominal pain, nausea, and vomiting. On admission to the ED the patient was found to be in sepsis; within 4 h he developed septic shock. CT scan of the abdomen showed impacted fecal matter in a significantly distended left and sigmoid colon. This was associated with colitis, extensive fat stranding and free fluid, without pneumoperitoneum. The patient was taken to the operating room for exploration where he underwent an extended left colectomy and Hartmann's procedure. Pathology showed acute focal colitis with transmural necrosis. There were no signs of perforation or inflammatory bowel disease. The patient recovered and was discharged home on post-operative day 8. Upon follow up on post-operative day 22, he was doing well. CLINICAL DISCUSSION: This case illustrates a very rare and challenging scenario. Complications of stercoral colitis include: stercoral ulcer, perforation, ischemic colitis, sepsis and death. Peritonitis, sepsis and bowel necrosis without perforation is extremely rare with very few cases reported in the literature. Colectomy with diversion is the mainstay of therapy. CONCLUSION: It is of paramount importance for ED providers and general surgeons to be aware of this condition. It presents a diagnostic challenge and carries an elevated mortality. Elderly patients on chronic opioids and those with mental impairment are at a higher risk.

Adults Hirschsprung's disease, a call for awareness. A Case Report and review of the literature.

Hirschsprung's disease (HD) is an uncommon condition in adulthood; the term adult HD denotes diagnosis after the age of ten. Patients suffer from constipation for many years before the diagnosis is established. They have very characteristic radiologic findings; however, the diagnosis is confirmed with full thickness biopsies. We describe the case of a 19-year-old Caucasian female patient from Southeast Missouri with a history of chronic constipation who was referred to the General Surgery Department by her primary care provider (PCP) due to massive colonic and rectal dilation in an abdominal CT scan. After rectal biopsies were performed the diagnosis of Hirschsprung's disease was confirmed. She was referred to a tertiary center where she underwent a colo-anal pull through procedure. She has been doing well for three years. Diagnosis of this condition can be very challenging, hence the need for clinical suspicion, good quality biopsies and inter-specialty communication among PCPs, gastroenterologists, surgeons and pathologists. Surgery aiming to remove or bypass the aganglionic colonic or rectal segment is the standard of care; quality of life can be significantly improved after surgery.

Abdominal wall endometriomas. Should the approach vary based on its relationship to the fascia? A case report and review of the literature.

INTRODUCTION: Abdominal wall endometrioma (AWE) is a rare encountered condition with a prevalence of 1-2%. Multiple diagnostic and treatment modalities are available; however, no clear guidelines exist. On occasions muscle and fascia excision might be necessary to achieve a clear margin. To avoid mesh complications, we believe the treatment should depend on tumor location in relation to the abdominal wall fascia. As far as we know this approach has not been previously discussed. PRESENTATION: A 29-year old female with a surgical history of 3 C-sections presented to us with 6 months of cyclical abdominal pain in the left lower quadrant. Imaging studies confirmed the presence of a mass overlying the left lower rectus abdominis muscle. After imaging studies, the mass was surgically excised. Pathology confirmed a benign endometrioma. DISCUSSION: Unfortunately, the surgical literature has not established a consensus on the best approach for diagnosis and management of this condition. The purpose of this report is to not only to present another case of this rare phenomenon, but to address the need for guidelines and review the current diagnostic and treatment available options. We also attempt to increase the awareness of this condition, it's unlikely malignant degeneration and potential morbidity of surgical excision. CONCLUSION: Surgical excision remains the standard of care for AWEs. In those patients where the fascia and muscle must be excised, we recommend less invasive modalities to avoid mesh complications. The need for guidelines remains.

Do lodged foreign bodies in the neck need to be removed? No defined criteria in 2020. Fluoroscopy role and review of literature: A case report.

Penetrating neck wounds can be fatal and require prompt attention. The trauma literature is flooded with management protocols for penetrating wounds to the neck; however, in the absence of hard signs the definitive management of lodged foreign bodies beyond the platysma is less clear. This report describes a work-related injury of a Caucasian 33-year-old male who arrived in the Emergency Department (ER) with a 1 cm metallic foreign body (FB) lodged in zone II of the neck, 7 mm antero-lateral to the right internal carotid artery. The technical aspects of its retrieval are discussed as well as a literature review of the current management of embedded FBs in the neck. The patient was taken to the operating room and the FB was removed via a 3 cm incision. Fluoroscopy was used for exact localization of and to allow a precise skin incision overlying the FB. The FB was retrieved uneventfully; a fiberoptic esophagoscopy and bronchoscopy showed normal findings. The patient was discharged home the next day. At 15 months follow-up he is doing well without sequela. The use of fluoroscopy is strongly encouraged for FB removal in asymptomatic patients. The management of lodged foreign bodies in the neck should be part of future guidelines.

Surgical outcomes and their relation to the number of prior episodes of diverticulitis.

PURPOSE: We aimed to investigate the relationship between the number of prior episodes of diverticulitis and outcomes of sigmoid colectomy. METHODS: After institutional review board approval, a retrospective review was undertaken based on records of patients who underwent sigmoid resection with anastomosis for diverticulitis between 4 May 2007 and 29 February 2012. Patients were divided into two groups: 0-3 attacks (group 1) and ≥4 attacks (group 2). Statistical analyses were performed to determine whether the groups differed on demographic, intra-operative and postoperative variables. RESULTS: We identified 247 patients who underwent sigmoid colectomy for diverticulitis (45 open, 202 laparoscopic). The two groups did not differ significantly in age, gender, American Society of Anesthesiologists score, past surgical history, body mass index, length of stay, use of a stoma or number of prior hospitalizations for diverticulitis. Group 1 had a higher rate of abscesses (30.6 vs 6.8%, P < 0.001) and fistulas (19.4 vs 0.9%, P < 0.001); a longer operative time (190.1 vs 166.3 min, P = 0.0024); and higher rates of postoperative complications (45.8 vs 23.3%, P < 0.001) and conversion (17.1 vs 4.4%, P = 0.0091). The most common surgical complications in groups 1 and 2 were wound infection (35 vs 10) and ileus (20 vs 8). Based on multivariate regression analysis, ≥4 attacks were independently correlated with a lower complication rate (odds ratio = 0.512, 95% confidence interval = 0.266-0.987, P = 0.046). CONCLUSIONS: Patients who had ≥4 previous attacks of diverticulitis had fewer postoperative complications.

Diagnóstico de sepsis neonatal bacteriana temprana

Se buscaron los criterios de con los cuales se realizó el diagnóstico de sepsis neonatal bacteriana temprana en el Servicio de Neonatología del Hospital Central de Aeronaútica del 1 de enero de 1989 al 31 de diciembre de 1994. Se revisaron 81 historias de neonatos con el diagnóstico de sepsis neonatal de origen bacteriano, con presentación temprana. El tipo de estudio fue transversal. Se revisaron las historias en la sección de registros del hospital, se anotaron en una ficha los antecedentes, signología y exámanes de laboratorio relacionados al momento del diagnóstico con la enfermedad. Para el análisis estadístico se utilizaron distribuciones de frecuencias absolutas y relativas, como medida de tendencia central, moda. Se encontró que en los antecedentes relacionados al cuadro, infección materna del tracto urinario, tuvo la mayor frecuencia como factor de riesgo con 38.3 por ciento del total de casos. La signología más comunmente hallada fue taquipnea en un 40.7 por ciento, seguido de piel fría distal, letargo, tremores y distensión abdominal, los exámenes de laboratorio inespecíficos más frecuentemente patológicos fueron el examen de orina y frotis de aspirado gástrico cada uno en 43.2 por ciento. Catorce pacientes tuvieron un cultivo positivo, de ellos nueve hemocultivos. Se aisló Klebsiella sp y estafilococo epidermis de 4 casos cada uno. La presencia conjunta de antecedentes, signología y exámenes laboratoriales patológicos fue en el 60.5 por ciento de casos