Stercoral Perforation of Sigmoid Colon in Systemic Lupus Erythematosus: A Rare Cause of Peritonitis.

Stercoral perforation (SP) is a rare cause of peritonitis. It is caused by pressure necrosis of the colonic wall by fecaloma. SP is a lethal condition that is associated with high morbidity and mortality, therefore early diagnosis and treatment are of paramount importance. Herein, we describe a case of SP in a systemic lupus erythematosus (SLE) patient. A 44-year-old female, known case of SLE, presented with severe abdominal pain, fever, and hypotension. CT scan showed features of perforated sigmoid. The patient underwent exploratory laparotomy which revealed perforation of sigmoid, fecalomas in the peritoneal cavity, and colon loaded with fecal matter. The patient underwent Hartmann's operation with successful control of her intra-abdominal sepsis. Her postoperative course was complicated by SLE flare and wound dehiscence which was probably due to long term steroid use. Even though SP is rare, it carries a worse prognosis especially if the patients are immunocompromised. The key to successfully manage such cases is early diagnosis, aggressive resuscitation, antibiotics, and prompt surgical intervention. A multidisciplinary approach is often helpful in such cases.

Isolated Dissections of Superior Mesenteric and Celiac Arteries Associated With Aortic Ectasia.

Arterial dissection is defined as a tear in the inner lining of arteries, leading to the passage of blood between the layers and resulting in a false lumen. Arterial dissection involving the aorta is commonly seen in clinical practice; however, dissections involving the celiac and superior mesenteric arteries are quite rare. Even rare are isolated multiple visceral arterial dissections. A 59-year-old male with uncontrolled hypertension presented with epigastric pain. CT angiography revealed isolated dissection of the celiac and superior mesenteric arteries with ascending aortic ectasia, with no features of ischemia or organ dysfunction. He was managed conservatively with analgesics & anticoagulation. Repeat CT angiography after six months of anticoagulation therapy showed no progression of the disease. Isolated multiple visceral arterial dissection is a rare vascular disease that requires a high index of suspicion to diagnose. CT angiography is a useful imaging modality that helps not only in diagnosis but also in choosing a treatment plan. Though treatment options are controversial, conservative treatment with anticoagulation should be considered in uncomplicated cases of visceral arterial dissections.

Idiopathic Retroperitoneal Non-pancreatic Pseudocyst in an Adult Male: Radiological Images and Surgical Video of Laparoscopic Excision.

Retroperitoneal pseudocyst (RPC) is an uncommon surgical entity. The pseudocyst is characterized by the absence of epithelial lining in the cyst wall. Mostly, it occurs as a sequela of pancreatitis. Pseudocyst due to a non-pancreatic cause, however, is very rare. We report a 49-year-old male, who presented to the emergency department with moderate intensity lower abdominal pain. Computed tomography scans revealed a huge retroperitoneal cyst which was overlying the right ureter and right iliac vessels. The patient underwent laparoscopic excision of the cyst and recovered without any complications. Histopathological examination showed a non-pancreatic RPC. In conclusion, non-pancreatic RPC is a rare surgical disease which can result in pressure symptoms depending on its location and size. In our patient, it was treated by laparoscopic excision despite its proximity to iliac vessels and ureter. A laparoscopic approach using safe surgical principles is a viable option for non-pancreatic RPC. The proximity of the lesion to the iliac vessels and the ureter can be carefully navigated safely by laparoscopy. The ureter can be confirmed by stimulating peristalsis of the duct when in doubt.

Strangulated Internal Hernia through Appendicular Tourniquet/Ring: Unusual Cause of Intestinal Obstruction.

BACKGROUND Intestinal obstruction secondary to internal hernia is a rare phenomenon in adults particularly in patients with history of pulmonary tuberculosis, but commonly seen in pediatric population. Mostly it occurs along the duodenum in the paraduodenal recesses. The patient might be misdiagnosed as having obstruction secondary to strictures formed as a result of intestinal tuberculosis and pose delay in exploration. CASE REPORT We describe an adult patient who presented with intestinal obstruction by a tourniquet or ring formed between the tip of appendix and ileocecal junction through which small bowel herniated, strangulated and finally perforated before exploration, initially thought to be due to intestinal tuberculosis. He underwent exploratory laparotomy and was release of obstruction, appendectomy and resection of bowel. The patient tolerated the procedure well and discharged in stable condition. CONCLUSIONS Intestinal obstruction due to internal hernia is rare in adults. Computed tomography abdomen can diagnose the condition; however, exploration of the abdomen can give the definite diagnosis and tailor the appropriate therapy.

Gallbladder volvulus with segmental right liver lobe hypoplasia/atrophy: a preoperative diagnostic dilemma.

Gallbladder volvulus (GBV) due to rotation of the gall bladder (GB) around its own mesentery is a rare surgical emergency and often identified intraoperatively. Typically, cholecystitis is the initial clinical diagnosis, but a high index of suspicion on imaging can alert the physician for the possibility of GBV requiring urgent surgical intervention. We describe a case of a young female patient with hypoplasia/atrophy of the posterior segment of the right liver lobe and a GB with no hepatic attachments but only mesenteric pedicle. She presented with first episode of sudden-onset, severe right subcostal pain. The ultrasonogram and magnetic resonance cholangiopancreatogram findings were suggestive of GBV. She underwent laparoscopic exploration that confirmed GBV of a free-floating GB with a thrombosed cystic artery. The GB was detorted, and cholecystectomy was performed. She had an uneventful postoperative course and was discharged with no complications. Histopathological examination showed intramural haematoma of the GB with wall necrosis.

Utility of extended FAST in blunt chest trauma: is it the time to be used in the ATLS algorithm?

INTRODUCTION: The clinical significance of extended Focused Assessment with Sonography for Trauma (EFAST) for diagnosis of pneumothorax is not well defined. OBJECTIVES: To investigate the utility of EFAST in blunt chest trauma (BCT) patients. STUDY DESIGN: A single blinded, prospective study. PARTICIPANTS: All patients admitted with BCT (2011-2013). SETTINGS: Level 1 trauma center in Qatar. PROCEDURES AND OUTCOME MEASURES: Patients were screened by EFAST and results were compared to the clinical examination (CE) and chest X-ray (CXR). Chest-computed tomography (CT) scoring system was used to confirm and measure the pneumothorax. Diagnostic accuracy of diagnostic modalities of pneumothorax was measured using sensitivity, specificity, predictive values (PVs), and likelihood ratio. RESULTS: A total of 305 BCT patients were included with median age of 34 (18-75). Chest CT was positive for pneumothorax in 75 (24.6 %) cases; of which 11 % had bilateral pneumothorax. Chest CT confirmed the diagnosis of pneumothorax in 43, 41, and 11 % of those who were initially diagnosed by EFAST, CE, and CXR, respectively. EFAST was positive in 42 hemithoraces and its sensitivity (43 %) was higher in comparison to CXR (11 %). Positive and negative PVs of EFAST were 76 and 92 %, respectively. The frequency of missed cases by CXR was higher in comparison to EFAST and CE. The lowest median score of missed pneumothorax was observed by EFAST. CONCLUSION: EFAST can be used as an efficient triaging tool in BCT patients to rule out pneumothorax. Based on our analysis, we would recommend EFAST as an adjunct in ATLS algorithm.