Delayed presentation of sigmoid volvulus in a young woman.

Volvulus is an unusual condition in Western countries, generally isolated to elderly patients with multiple comorbidities. This report describes an unusual case of a very large gangrenous sigmoid volvulus in a young, otherwise healthy 25-year-old female. A review of the diagnosis and management is subsequently described. Without a consideration of the atypical demographics for sigmoid volvulus, the case illustrates the potential morbidity due to a delayed diagnosis. Early identification and management are crucial in treating sigmoid volvulus before the appearance of gangrene and necrosis, thereby avoiding further complications and associated mortality.

Surgical outcome of community-acquired Clostridium difficile colitis presenting as toxic megacolon: case report.

BACKGROUND: Over the past decade, there has been an increase in both community-acquired and health-care-associated Clostridium difficile colitis secondary to broad-spectrum antibiotic exposure. Toxic megacolon is a rare complication of pseudomembranous colitis that often necessitates emergency colectomy. METHODS: Review of the pertinent English-language literature. RESULTS: We present a case of community-acquired C. difficile colitis that made its initial presentation as fulminant toxic megacolon. Six months after a total colectomy, the patient has no complaints. CONCLUSION: Prompt total colectomy may improve survival in patients with toxic megacolon. The incidence of C. difficile-related toxic megacolon and post-operative outcomes of total colectomy should be investigated in a larger observational study.

Laparoscopic management of a duplicated gallbladder: a case study and anatomic history.

Duplication of the gallbladder is a rare entity. This case highlights a 36-year-old woman who presented to Arrowhead Regional Medical Center after referral from an outside institution with gallstone pancreatitis. Ultrasound, computed tomography scan, and magnetic resonance cholangiopancreatography showed evidence of a biliary anomaly preoperatively concerning for a duplicated gallbladder or choledochal cyst. Subsequent laparoscopic cholecystectomy and intraoperative cholangiogram confirmed the presence of a duplicated gallbladder. A second intrahepatic gallbladder with connection to the right hepatic duct was identified and the first gallbladder's connection to the common hepatic duct was noted. Both gallbladders contained hundreds of small stones. The patient did well postoperatively and has had no adverse sequelae. A literature review revealed an incidence of 1 in 4000 autopsies with a duplicated gallbladder. Sixty-seven case reports have been published and only 20 cases were managed laparoscopically.

Evaluation of prehospital and emergency department systolic blood pressure as a predictor of in-hospital mortality.

Hypotension is a trauma activation criterion validated by multiple studies. However, field systolic blood pressures (SBP) are still met with skepticism. How significant is the role of prehospital (PH) and emergency department (ED) SBP in the patient's overall condition? A review of the trauma registry over a 5-year period was conducted. PH SBPs were stratified into four categories: severe (SBP 80 mmHg or less), moderate (81-100 mmHg), mild hypotension (101-120 mmHg), and normotension (greater than 120 mmHg). These four groups were further subcategorized into the patients who were hypotensive, SBP 90 mmHg or less in the ED, versus those that were not (SBP greater than 90 mmHg). Data for 6964 patients were analyzed. Patients with PH SBP of 80 mmHg or less compared with patients who had PH SBP of greater than 80 mmHg had higher mortality (OR, 9; 95% CI, 6.45-12.84). Patients with both PH SBP 80 mmHg or less and ED SBP 90 mmHg or less had the highest risk of mortality (50%) and highest need for emergent operative intervention (54%). PH and ED hypotension is a strong predictor of in-hospital mortality and need for emergent surgical intervention in trauma patients. Field or ED blood pressures should serve as a significant marker of the patient's condition.

Abdominal computed tomography in the evaluation of acute and perforated appendicitis in the community setting.

Several studies report sensitivity and specificity of abdominal computed tomography scans (CT) for the evaluation of acute appendicitis as high as 98 per cent. Despite increased utilization of CT, the rate of negative appendectomy has remained constant at 10 to 20 per cent. The objective of this study was to assess the effectiveness of CT in the evaluation of acute and perforated appendicitis in an academic community-based setting. A retrospective review of 550 patient charts with International Classification of Diseases-9 (ICD-9) codes for acute and perforated appendicitis from January 2002 to October 2005 was performed. Sensitivity of CT was 87 per cent with a positive predictive value of 92 per cent. Specificity was 42 per cent with a negative predictive value of 29 per cent. Negative appendectomy rates were similar with or without CT (11% vs. 13%, respectively). Our data suggests that CT used liberally in everyday practice in a community-based setting to evaluate acute appendicitis may not have as strong of a diagnostic value as those used in protocol-driven research studies. Further prospective studies are needed to formulate criteria to better delineate the role of CT in the evaluation of acute appendicitis.