Evaluating the Emergency Surgery Score (ESS) in Predicting Postoperative Outcomes Following Emergency Laparotomy: Insights From an Indian Tertiary Center.

AIMS AND OBJECTIVES:  To determine the predictive value of Emergency Surgery Score (ESS) with regard to mortality and morbidity rates of patients undergoing emergency laparotomy. METHOD: The ESS ranging from 0 to 29 is an extensive risk calculator based on 22 variables including important parameters like demographics, preoperative treatment, comorbidities, and laboratory values. Twenty patients who underwent emergency laparotomy were preoperatively assessed and ESS was calculated for each. After establishment of diagnosis and resuscitation, the patient was taken up for emergency laparotomy. Postoperatively, patients were monitored clinically as well as with laboratory and radiological investigations as per case needed till discharge and further followed up physically in OPD/ward or interviewed telephonically for 30 days on a weekly basis. Incidence of mortality and morbidity in terms of postoperative complications, ICU admission, reoperation and readmission among the cases occurring within 30 days of procedure were recorded. RESULTS: ESS correlated well with the outcome in the current study, 10 out of 14 patients with score less than 8 were discharged without any complications. Mean ESS was higher among non-survivors. Ability of ESS to predict postoperative mortality, morbidity and ICU stay was proven statistically with c-statistics of 0.853, 0.84, 0.879 respectively. ESS was found to be a good predictor for the development of postoperative lower respiratory tract infection (LRTI) (c-statistic=0.828), sepsis (c-statistic=0.867), disseminated intravascular coagulation (DIC) (c-statistic=0.805), acute kidney injury (AKI) (c-statistic=0.804). ESS showed poor correlation with reoperation and readmission rates. CONCLUSION: The current study underscores the critical importance of employing risk stratification through ESS for patients undergoing emergency laparotomy. By employing ESS, healthcare professionals can accurately anticipate resuscitation requirements and stabilize patients preoperatively. This proactive approach enables the identification and optimization of patients unsuitable for immediate surgery, facilitating informed decisions on targeted treatment, surgical intervention, and postoperative care pathways.

Acute Abdomen in Pregnancy: A Comprehensive Review of Diagnosis and Management.

An unusual diagnostic and treatment challenge is presented by an acute abdomen during pregnancy. Obstetric factors and other causes unrelated to pregnancy also contribute to acute abdominal discomfort in pregnancy. Due to the changing clinical presentations brought on by the anatomical and physiological changes of pregnancy as well as the hesitation to utilize certain radiological studies out of concern about damaging the fetus, the diagnosis of the acute abdomen during pregnancy can be challenging. Delays in identification and treatment may have negative effects on the mother as well as the fetus. This review sheds light on the importance of anatomical and physiological considerations, early diagnoses, and understanding the various modalities and etiologies of acute abdomen in pregnancy (AAP). We then move on to discuss the various diagnostic techniques that can help the physician determine the causes and plan well-informed treatment. We examine and contrast different radiographic tests, including X-rays, computed tomography, magnetic resonance imaging, and ultrasound. We also talk about the various roles that these investigational methods can play in the evaluation and treatment throughout the duration of the pregnancy. The paper additionally addresses how to handle patients who appear with AAP and the different techniques used to treat them, including pre-operative laparoscopy. Before going over some more broad points that might be useful, we eventually dive into some of the more intriguing etiologies relating to AAP, such as isolated tubal torsion and neoplastic complications.

Epiploic appendagitis: a commonly undiagnosed non-surgical acute abdominal emergency.

Epiploic appendagitis is a rare cause of acute abdomen and is diagnostically challenging as it mimics common causes of acute abdomen. However, advancements in computerised tomography/Ultrasound imaging have improved the frequency and confidence of diagnosing epiploic appendagitis, preventing unnecessary surgeries. We present a case of an acute abdomen who had to undergo laparoscopy before being diagnosed with epiploic appendagitis, underscoring the difficulty in diagnosis.

Synchronous Acute Appendicitis and Acute Cholecystitis.

The occurrence of synchronous acute cholecystitis and appendicitis is rare. There are few cases reported and small series in the literature. We report the case of a 77-year-old male who presented to the emergency department with right-sided abdominal pain. He was diagnosed preoperatively with acute calculous cholecystitis. During the initial laparoscopy, a complicated appendiceal phlegmon was found and was treated with a one-step laparoscopic approach and subsequent antibiotics. The patient had an uneventful recovery and was discharged on postoperative day (POD) 2. The pathology report confirmed both diagnoses and an incidental low-grade appendiceal mucinous neoplasm. Although uncommon, it is important to be aware of the possibility of both simultaneous pathologies in a patient who presents to the emergency department with abdominal pain.

Stress Hyperglycemia Secondary to Abdominal Emergency Mimicking Diabetic Ketoacidosis in a Pediatric Patient.

Abdominal pain in a pediatric patient with diabetic ketoacidosis (DKA) can be mistaken for surgical or septic causes of acute abdomen. Both DKA and surgical abdominal emergencies can cause lactic acidosis (LA), which makes it challenging to differentiate between them. Fluid therapy resulting in quick alleviation of metabolic acidosis could be a valuable sign in differentiating surgical abdomen from DKA. In this report, we present a case of the surgical abdomen with stress hyperglycemia that mimicked DKA.

Factors associated with delayed reporting for surgical care among patients with surgical acute abdomen attended at Muhimbili National Hospital: Tanzania.

BACKGROUND: Surgical acute abdomen is a sudden onset of severe abdominal symptoms (pain, vomiting, constipation etc.) indicative of a possible life-threatening intra-abdominal pathology, with most cases requiring immediate surgical intervention. Most studies from developing countries have focused on complications related to delayed diagnosis of specific abdominal problems like intestinal obstruction or acute appendicitis and only a few studies have assessed factors related to the delay in patients with acute abdomen. This study focused on the time from the onset of a surgical acute abdomen to presentation to determine factors that led to delayed reporting among these patients at the Muhimbili National Hospital (MNH) and aimed to close the knowledge gap on the incidence, presentation, etiology, and death rates for acute abdomen in Tanzania. METHODS: We conducted a descriptive cross-sectional study at MNH, Tanzania. Patients with a clinical diagnosis of the surgical acute abdomen were consecutively enrolled in the study over a period of 6 months and data on the onset of symptoms, time of presentation to the hospital, and events during the illness were collected. RESULTS: Age was significantly associated with delayed hospital presentation, with older groups presenting later than younger ones. Informal education and being uneducated were factors contributing to delayed presentation, while educated groups presented early, albeit the difference was statistically insignificant (p = 0.121). Patients working in the government sector had the lowest percentage of delayed presentation compared to those in the private sector and self-employed individuals, however, the difference was statistically insignificant. Family and cohabiting individuals showed late presentation (p = 0.03). Deficiencies in health care staff on duty, unfamiliarity with the medical facilities, and low experience in dealing with emergency cases were associated with the factors for delayed surgical care among patients. Delays in the presentation to the hospital increased mortality and morbidity, especially among patients who needed emergency surgical care. CONCLUSION: Delayed reporting for surgical care among patients with surgical acute abdomen in underdeveloped countries like Tanzania is often not due to a single reason. The causes are distributed across several levels including the patient's age and family, deficiency in medical staff on duty and lack of experience in dealing with emergency cases, educational level, working sectors, socioeconomic and sociocultural status of the country.

COVID-19 Infection and Acute Pancreas Transplant Graft Thrombosis.

The coronavirus disease 2019 (COVID-19) pandemic created an unprecedented challenge for healthcare, and the world continues to struggle in recovering from its aftermath. COVID-19 has been clearly linked to hypercoagulable states and can lead to end-organ ischemia, morbidity, and mortality. Immunosuppressed solid organ transplant recipients represent a highly vulnerable population for the increased risk of complications and mortality. Early venous or arterial thrombosis with acute graft loss after whole pancreas transplantation is well-described, but late thrombosis is rare. We herein report a case of acute, late pancreas graft thrombosis at 13 years post pancreas-after-kidney (PAK) transplantation coinciding with an acute COVID-19 infection in a previously double-vaccinated recipient.

Neutrophil-to-Lymphocyte Ratio as an Early Predictor of Complication and Mortality Outcomes in Individuals With Acute Pancreatitis at a UK District General Hospital: A Retrospective Analysis.

Aim The purpose of this study was to evaluate the predictive usefulness of the neutrophil-to-lymphocyte ratio (NLR) in patients with acute pancreatitis (AP) and establish a threshold for the prediction of poor outcomes. Methods For this investigation, we looked back at all cases of acute pancreatitis treated at Torbay Hospital in Torquay, UK, between January 1st, 2019, and December 31st, 2020. Those who were found to have chronic pancreatitis or whose baseline laboratory values could not be obtained were not included. Each patient's entire hospital stay was analyzed, including up to 72 hours of medical and laboratory data. Results According to the Glasgow Coma Scale scoring system, 28 of the 314 included patients had severe acute pancreatitis, and 81 patients had pancreatitis with complications. Those with complications had a substantially higher NLR on day 1 (9.43 ± 7.57) than patients who recovered without complications (7.37 ± 5.88) (P-value = 0.028). The NLR on day 0 (>18.71) exhibited a sensitivity of 80%, a specificity of 90.2%, and an accuracy of 83.9% in forecasting the death of patients with pancreatitis. Conclusion Elevated baseline NLR corresponds with pancreatitis with complications and can predict mortality.

Bilirubin as a Predictor of Complicated Appendicitis in a District General Hospital: A Retrospective Analysis.

Aims The objectives of the study were to establish the function of bilirubin as a novel diagnostic tool for predicting complex appendicitis and to compare the impact of other variables such as white blood cell count (WCC), C-reactive protein (CRP), and neutrophil. Methods This retrospective, single-center cohort analysis included all patients admitted to Torbay General Hospital in Torquay, United Kingdom, between January 2020 and December 2020 with a clinical diagnosis of acute appendicitis. In addition to serum CRP, WCC, and neutrophil, serum bilirubin and other liver enzymes were obtained from the patients' blood on admission. Results The quantitative analysis included 174 patients from the group that remained. The large majority of the sample consisted of adults and males (77% and 51.7%, respectively). Overall, 49.4% of participants in the study were diagnosed with complicated appendicitis; 74.7% of adults had complicated appendicitis, with 58.6% being male. In 68.6% of cases, perforated appendicitis was the most prevalent form of complicated appendicitis. Patients with complicated appendicitis had significantly higher WCC, neutrophil, and CRP levels than those with uncomplicated appendicitis (14.15 vs. 12.88, p = 0.016; 11.63 vs. 10.19, p = 0.007; and (89.28 vs. 40.65, p = 0.0001, respectively).. The significantly greater alkaline phosphatase and total serum bilirubin discrepancies were observed in patients with complicated appendicitis. There were statistically significant differences in the means of the patients: (18.46 vs. 10.98, p = 0.0001 and 110.64 vs. 102.24, p = 0.033). Conclusion Serum bilirubin is a crucial diagnostic aid for determining the existence of complicated appendicitis.

Single-Center Retrospective Analysis of Neutrophil, Monocyte, and Platelet to Lymphocyte Ratios as Predictors of Complicated Appendicitis.

Aim We look at the ability of the neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and monocyte-to-lymphocyte ratio (MLR) to differentiate between uncomplicated and complicated appendicitis. Methods and materials This was a retrospective, single-center study of 234 individuals diagnosed with acute appendicitis between January 1, 2020, and December 31, 2020. Patients were grouped into uncomplicated and complicated appendicitis subgroups. Patients with histologically or radiologically proven gangrenous or perforated appendicitis, as well as those with peritonitis or peri-appendiceal abscess development, comprise the complicated subgroup. Independent Mann-Whitney samples The U test was used to predict lab values of complicated appendicitis. Furthermore, the receiver operating characteristic (ROC) curve and area under the curve (AUC) were utilized to predict the sensitivity and specificity of laboratory results reported to have a significant connection with complex appendicitis Results The criteria were met by 186 patients, with a male-to-female proportion of 1.06:1, an average age of 36.4 years, and an average stay of 2.73 days. There were 95 individuals with complicated appendicitis. With 66.3%, perforated appendicitis was the most prevalent condition. The ratios of neutrophils to lymphocytes, monocytes to lymphocytes, and platelets to lymphocytes were linked with complicated appendicitis with a p-value of < 0.0001, and p-values = 0.015, and 0.015, respectively. Conclusion NLR, MLR, and PLR are valid, less onerous surrogate biomarkers for measuring the severity of acute complicated appendicitis and differentiating it from uncomplicated appendicitis.

A Surgical Presentation of Churg-Strauss Syndrome.

Eosinophilic granulomatosis with polyangiitis (EGPA) or Churg-Strauss syndrome (CSS) is a rare, autoimmune vasculitis usually affecting small and medium-sized blood vessels in its later phases. It is a diffuse, systemic, multisystem disease that is reported to present with gastrointestinal manifestations but very rarely as an acute abdomen secondary to eosinophilic peritonitis. A 28-year-old relatively healthy male with a pre-existing diagnosis of inactive pulmonary sarcoidosis presented to the emergency department with an acute abdomen. After an exploratory laparotomy, multi-specialty involvement, and extensive investigations to exclude other differentials, a diagnosis of EGPA was made. The patient was treated with systemic glucocorticoids initially, followed by a tapering course of steroids and anti-interleukin 5 monoclonal antibodies as maintenance upon remission. EGPA can manifest in a myriad of ways including an acute abdomen, and medical treatment is useful in managing this presentation. Surgeons should be aware of the atypical causes of acute abdomen and should routinely broaden their differential diagnosis to include medical pathologies.

Hospital-Acquired COVID-19 Infection Increases Morbidity and Mortality: A Case Report of Post-Surgical Challenge of Duodenal Ulcer Repair During COVID-19 Era.

Hospital-acquired infections are nosocomially acquired infections that are not present or incubating at the time of admission to a hospital. During the COVID-19 pandemic, many hospitals became sources of the infection, creating a great challenge for health care providers and uninfected patients who visited these hospitals seeking medical or surgical advice. We are presenting a middle-aged man who complained of abdominal pain associated with poor oral intake during the COVID-19 pandemic in January 2021. After being diagnosed with a perforated duodenal ulcer, he underwent laparoscopic repair. He was postoperatively referred to interventional radiology for central line insertion. However, as one of the pre-procedure perquisites during the COVID-19 pandemic, he underwent a nasopharyngeal swab real-time PCR test, which was positive for COVID-19 infection to be considered hospital-acquired. This article shows how the pandemic may complicate the post-surgical condition, increasing patient morbidity and mortality.

Diagnostic Overshadowing and Pain Insensitivity in a Schizophrenic Patient With Perforated Duodenal Ulcer.

Some patients with schizophrenia and psychotic illnesses have reduced pain perception, and others have decreased pain expression. The diagnosis of the acute abdomen can be delayed, and its outcomes can be worse in psychiatric patients than in non-psychiatric patients. We present a case of perforated peptic ulcer (PPU) in a schizophrenic woman and discuss how the phenomenon of pain insensitivity and diagnostic overshadowing-a process in which a person with mental illness receives inadequate treatment due to a misattribution of physical symptoms to their mental illness-nearly contributed to a missed diagnosis.

Meckel's Enterolith Causing Small Bowel Obstruction: A Useful Solution to a Unique Problem.

Meckel's diverticulum (MD) is the most common congenital anomaly of the gastrointestinal tract. Its course is usually benign but may also result in complications requiring surgical intervention. A diverticulum may also permit the removal of intraluminal objects without bowel resection and anastomosis. A woman in her 50s was found to have a mechanical small bowel obstruction secondary to an intraluminal mass within the terminal ileum. On exploration, an MD was encountered proximal to the mass. A diverticulectomy was performed after maneuvering the enterolith into the diverticulum. Meckel's diverticulum with an associated enterolith is a rare cause of small bowel obstruction. Historic imaging may show long-standing stones in the bowel lumen and provide a diagnostic clue. Diverticulectomy may be performed to reduce the risks of small bowel resection and anastomosis. This technique can be used for other intraluminal objects requiring removal in the presence of an MD.

Strangulated Falciform Hernia.

Internal hernias are rare, and a delayed diagnosis can lead to dangerous complications. A 75-year-old male with no previous surgical history presented with right upper abdominal pain and vomiting. On examination, he had guarding in the right hypochondrium with a positive Murphy's sign. However, ultrasonography of the gall bladder was normal with dilated bowel loops. Contrast-enhanced CT (CECT) revealed a falciform hernia with evidence of obstruction. Segmental resection of the gangrenous ileum was done with a double-barrel stoma. Later on, stoma reversal was also done with no complications.

Partial Hydatidiform Mole in an Ectopic Tubal Pregnancy.

Fallopian tubal molar pregnancy is extremely rare, and the main diagnostic tool is the post-operative histopathological diagnosis, as the pre-operative diagnosis is difficult. We report a case of ectopic partial molar pregnancy in the right fallopian tube of a 35-year-old lady that was sent for routine histopathological examination with the clinical diagnosis of ectopic pregnancy and the histopathology report revealed an unusual result.

Oclusión intestinal por nudo ileosigmoideo / Intestinal occlusion by Ileosigmoid Knot

La oclusión intestinal es una causa frecuente de abdomen agudo quirúrgico. Dentro de sus múltiples casusas se encuentra el nudo ileosigmoideo, entidad rara en el mundo, pero puede verse con relativa frecuencia en algunas latitudes geográficas como Asia, Medio Oriente y otros países del continente africano. El objetivo de este trabajo es presentar cuatro casos de pacientes con oclusión intestinal por nudo ileosigmoideo en los hospitales Souro Sanu de Bobo Diulaso, Burkina Faso y Wa Regional Hospital, de Gana. Se intervinieron quirúrgicamente, se hizo resección en bloque de los segmentos ileales y sigmoideos gangrenados con anastomosis íleo-ascendente y colostomía de tipo Hartman. Los pacientes evolucionaron satisfactoriamente y luego de tres meses se restableció definitivamente el tránsito intestinal. Se realizó una revisión de la literatura(AU)

Intestinal occlusion is a frequent cause of surgical acute abdomen. Among its multiple causes are the ileosigmoid knot, a rare entity worldwide, which is relatively frequent in some geographic areas such as Asia, Middle East and Africa. The objective of this paper was to present four patients with intestinal occlusion due to ileosigmoid knot in Souro Sanu of Bobo Diulaso hospitals in Burkina Faso and Wa Regional Hospital in Ghana. They were operated on through block resection of gangrenous ileal and sigmoid segments with ascending ileoanastomosis and Hartrman-type colostomy. The patients recovered satisfactorily and three months later, the intestinal transfer was finally re-established. A literature review on the topic was made(AU)

Small Intestine Ischaemia due to Volvulus during Pregnancy.

Small intestine ischaemia caused by volvulus is difficult to diagnose during pregnancy, as the signs and symptoms may be masked by pregnancy. An early diagnosis and a prompt surgical intervention is necessary, as morbidity and mortality of this disorder are significant. We are presenting a case of a 35-year-old pregnant woman with volvulus of small bowel.

Abdomen agudo quirúrgico hemorrágico. Embarazo heterotópico. Reporte de un caso / Hemorrhagic surgical acute abdomen. Heterotopic pregnancy. A case report

Métodos: Presentamos un caso de una paciente femenina de 31 años con dolor abdominal de fuerte intensidad, tipo punzante, en fosa iliaca derecha, de aparición brusca, con signos de irritación peritoneal y ß-HCG positiva, cuadro clínico de abdomen agudo quirúrgico por embarazo ectópico. Resultados: El resultado quirúrgico de la intervención arrojó una trompa derecha aumentada de tamaño, rota, sangrante y cuyo reporte de anatomía patológica fue un embarazo tubárico roto y aumento de volumen del útero de aspecto gestante. En el postoperatorio mediato se realiza ecosonograma transvaginal evidenciándose embarazo intrauterino de 7 semanas + 2 días, por lo cual fue egresada con el diagnóstico de embarazo heterotópico. Conclusión: Se define embarazo heterotópico como la gestación intrauterina y extrauterina que coexisten de forma simultánea. Este se manifiesta como cuadros de dolor abdominal, signos de shock hipovolémico y en raras ocasiones escaso sangrado genital. Es una patología poco frecuente cuando se presenta de manera espontánea(AU)

Methods: We present a case of a female patient aged 31 with abdominal pain of high intensity , sharp stabbing pain, right lower quadrant , with abrupt onset, with signs of peritoneal irritation and ß-HCG positive, disease pattern of acute abdomen ectopic pregnancy. Results: Surgical intervention resulted in a raised right Falopian tube, broken, bleeding and resulting pathology reported broken tubal pregnancy and increased uterine volume of pregnant look. In the immediate postoperative transvaginal sonogram is performed evidencing intrauterine pregnancy 7 weeks + 2 days, which was discharged with the diagnosis of heterotopic pregnancy. Conclusion: Heterotopic pregnancy is defined as intrauterine and extrauterine gestation coexisting simultaneously. This manifests as abdominal pain, signs of hypovolemic shock and rarely scarce genital bleeding. It is a rare disease when it occurs spontaneously(AU)