Ruptured metastatic ovarian carcinoma presenting as acute abdomen.

Acute abdomen is a challenge to first-line physicians because of frequently missed diagnoses and potential follow-on legal problems. Improving the management of these patients is of paramount importance, not only for saving lives, but also for reducing untoward problems associated with improper management. We present a case of a patient with acute abdomen due to intraperitoneal hemorrhage secondary to rupture of an ovarian tumor. Following emergency surgery, the patient was diagnosed with metastatic ovarian carcinoma. Because of improper preparation of the gastrointestinal tract, the patient underwent repeat exploratory laparotomy for colon carcinoma. Although this situation did not affect the outcome of the patient in this case, we are concerned that the patient did not benefit from a single operation, with primary complete excision of the tumor plus a colostomy. The outcome of patients with pelvic malignancy, especially those with ovarian carcinoma, might be better if initial surgery achieved optimal tumor debulking. This is possible with good preoperative planning and preparation. We emphasize the importance of preoperative preparation in spite of urgently needed care. Furthermore, every first-line physician should communicate the possibility of malignancy to patients and their families.

High resistance index of Doppler ultrasound in tuberculous peritonitis presenting as abdominal carcinomatosis: report of two cases.

The radiologic features of tuberculous peritonitis (TB peritonitis) are seldom reported, and the use of color Doppler ultrasound in the diagnosis of TB peritonitis is even less common. Herein, we present two patients (a 29-year-old woman and a 56-year-old woman) who were evaluated for months of progressive enlargement of the abdomen, poor appetite and weight loss. In both patients, clinical and laboratory examinations suggested carcinoma, except a very high vascular resistance (resistance index 1.0 and 0.89, respectively) of the tumor feeding vessels detected by color Doppler ultrasound. TB peritonitis was finally diagnosed by exploratory laparotomy. Both patients were treated using a four-drug regimen of isoniazid, rifampicin, ethambutol hydrochloride and pyrazinamide for nine months and were clinically cured. In conclusion, if color Doppler ultrasound reveals normal ovaries, ascites containing thin, delicate incomplete or complete septa, and only a few high-resistance tumor feeding vessels in the abdominal cavity (resistance index > or = 0.80), TB peritonitis should be considered.

Placenta previa accreta with cervical involvement causing tenacious postpartum hemorrhage: a case report.

Conservative treatment for placenta accreta has recently been popularly accepted even though serious postpartum hemorrhage, resulting in maternal death, may occur. We report a case of placenta previa accreta with cervical involvement resulting in tenacious postpartum hemorrhage. A 28-year-old pregnant woman, gravida-2 para-1, who had undergone a previous cesarean section, was scheduled for a repeat cesarean section because of complete placenta previa associated with placenta accreta. The patient underwent cesarean section and delivered a 3,700 g, male infant. Manual removal of the placenta was performed with some difficulty and redundant placental tissue remained adhered to the uterine wall. Oxytocin, ergometrine, uterine arterial ligation and packing of the lower uterine segment were used to control bleeding; the wound was closed as usual after achieving adequate hemostasis. While closing the abdominal wall, vaginal bleeding was noted. After conservative treatment, shock progressively emerged due to persistent vaginal bleeding. Emergency laparotomy found active bleeding from the cervix and total abdominal hysterectomy was performed without hesitation. Careful evaluation is mandatory to preserve the uterus. In the case of cervical involvement, aggressive treatment such as hysterectomy should be undertaken promptly to decrease the risks of both morbidity and mortality.

Serotonin, folic acid, and uric acid metabolism in the diagnosis of neuropsychiatric disorders.

Metabolic compensation appears possible within the serotonergic, folate, purine system and it seems possible that clinical illness may result when the system can no longer compensate. For example, elevated serotonin, induced by stress accumulation of tryptophan, could be compensated by a lowered folate ratio, normalizing the beta-carboline index and preventing hallucinations. Conversely, deficient serotonin, induced by a psychological loss or transport deficit, could be compensated by raising the folate ratio, which would normalize the beta-carboline index and prevent further depression. Increased purine turnover would seemingly lower the folate ratio, compensating perhaps for hallucinatory activity or mania. Several genetic defects of enzymes or transport proteins could seemingly preclude normal compensations within the system.