Combined Rupture of the Diaphragm and Urinary Bladder in Blunt Trauma Abdomen.

The authors examined a 25-year-old man with a combined rupture of the diaphragm and urinary bladder following blunt trauma to the abdomen. The presence of hematuria, suprapubic tenderness, and elevated serum urea and creatinine levels in this patient raised suspicion of urinary bladder rupture. Documentation of bowel gas shadows on the chest x-ray suggested underlying diaphragm injury. A computed tomogram of the thorax and abdomen confirmed the tear in the left hemidiaphragm with intrathoracic herniation of abdominal contents; however, it failed to detect the intraperitoneal urinary bladder rupture. Both the defects were identified and repaired during laparotomy. The sudden increase in intraabdominal pressure in blunt trauma to the abdomen often resulted in full-thickness tears of the diaphragm and the urinary bladder. Although radiological investigations were pivotal for assessing the damage to the internal organs, a methodical and thorough exploratory laparotomy was invaluable for successfully managing patients with blunt abdominal trauma.

Intra-abdominal Pressure Measurement as a Predictor of Postoperative Wound Complications in Patients Undergoing Emergency Laparotomy: A Prospective Observational Study.

Introduction Elevated intra-abdominal pressure (IAP) hampers the effective functioning of intra- and extra-abdominal organs. Despite the abundance of knowledge, routine measurement of IAP still needs to be widely incorporated in managing at-risk patients. The present study intends to assess the need for IAP measurement on abdominal wound healing in emergency laparotomy patients. Methods This prospective study was carried out over 24 months in patients undergoing emergency laparotomy. The IAP was measured at admission, immediately after surgery, and during the early postoperative period at 6, 12, 24, 48, and 72 hours. The patients were evaluated for the development of wound-related complications over a follow-up period of three months post-operatively. Results Seventy-two patients were enrolled. At admission, 54 (75%) patients had intra-abdominal hypertension (IAH), of which three patients had evidence of abdominal compartment syndrome. Thirty-one (43%) patients developed postoperative wound infections. The overall incidence of wound infection was significantly higher in patients with IAH (54.3% vs. 24%, p-value = 0.04, Pearson's Chi-squared test). The frequency of wound dehiscence was greater (19.6 % vs. 4.3 %, p-value 0.14, Fischer's exact test) in patients with IAH. The median duration of hospital stay (13 vs. 8 days, p-value 0.02, Mann-Whitney U test) and healing time (30.5 vs. 18 days, p-value 0.02, Mann-Whitney U test) was significantly higher in patients with IAH. Conclusion Measurement of IAP is a relatively simple procedure that should be incorporated into the routine postoperative care of surgical patients. The presence of elevated IAP can identify the subset of patients at risk of increased postoperative wound complications.

A Right-Angled Thorn in the Bowel: A Curious Case of Small Bowel Perforation.

We present a 45-year-old man with small bowel perforation resulting from the inadvertent ingestion of a right-angled thorn of the Gum Arabic plant (Vachellia nilotica). The diagnosis was made, and an emergency laparotomy was performed for suspected enteric peritonitis. The thorn was found projecting from the terminal ileum with a minimal intra-peritoneal fluid collection. The thorn was removed, and the perforation site was repaired primarily with absorbable sutures. The lack of a reliable history of foreign body ingestion makes it impossible to arrive at an accurate preoperative diagnosis in patients presenting with perforation peritonitis. Radiological investigations have a low sensitivity for detecting radiolucent vegetative foreign bodies as the cause of bowel perforations. Primary repair should be preferred over resection procedures in the management of foreign body-induced small bowel perforations.

Primary hydatid disease of fallopian tubes: the risk of infertility looms large.

A 45-year-old postmenopausal woman from a rural area presented with a painless lower abdominal lump. Contrast-enhanced computed tomogram of abdomen revealed a well defined hypodense pelvic cystic lesion with multiple daughter cysts suggestive of hydatid disease. The liver was free of cysts on imaging. On laparotomy, the cyst cavity was found to be communicating with the fimbriated ends of both the fallopian tubes. Cyst excision along with hysterectomy and bilateral salpingo-oophorectomy was performed. Histopathology confirmed presence of hydatid disease by demonstrating daughter cysts and laminated membrane completely filling up the tube lumens. The uterus and ovary were uninvolved. While the management is straightforward in postmenopausal women, the risk of infertility looms large in young patients with bilateral fallopian tube hydatid disease. Proper preoperative counseling is thus essential in the patients with pelvic hydatid disease to safeguard against future litigations.

Chromobacterium violaceum- induced sepsis and multiorgan dysfunction, resembling melioidosis in an elderly diabetic patient: A case report with review of literature.

An elderly diabetic farmer presented with chronic nonhealing ulcer over the left foot, multiple liver abscesses, and right-sided pleural effusion. The patient developed septicemia and multiorgan failure. The pus grew pigment producing Chromobacterium violaceum. He was treated successfully with ciprofloxacin for a total duration of 15 days. This case is reported for its rare clinical presentation and resemblance with melioidosis. Of the 200 C. violaceum cases reported across the globe, this is the 14th case from India and the oldest in the literature.

Inflammatory fibroid polyp (Vanek's tumour): my worst nightmare in the emergency department.

A middle-aged woman presented in shock with bleeding per rectum for 2 days without any significant past medical or surgical illness. Abdominal sonography, oesophagogastroduodenoscopy and sigmoidocolonoscopy were unremarkable. Despite 6 units of blood transfusion, 3000 mL of plasma expanders and ionotropes, the arterial pressure gradually decreased. We had no choice but to undergo life-threatening yet possibly life saving laparotomy. We found a 1×1 cm ileal bleeding mucosal polyp about 20 cm away from the ileocaecal junction. We resected and anastomosed end to end. Perioperatively, the patient was transfused with another 4 units of blood product. Immunohistopathology revealed a large number of CD34 positive spindle cells and eosinophils with extensive thick-walled capillaries compatible with inflammatory fibroid polyp. This case of Vanek's tumour is reported for its atypical site, which presented as massive obscure gastrointestinal haemorrhage without any prior warning signs.

Melioidosis as a cause of acute abdomen in immuno-competent male from eastern India.

Though melioidosis is rare in India, it has gained importance as one of the most potent emerging infections. In India, the cases have been under-reported because of the lack of awareness. The majority of cases present with multifocal pyogenic infections with septicemia. We present an unusual case of melioidosis presenting as acute intestinal perforation. The organism was ceftazidime resistant, and we successfully treated the case with imipenem and doxycyclin. This case highlights ruling out the possibility of melioidosis in acute abdomen and existence of ceftazidime resistant cases in India.