INTRA-ABDOMINAL INJURIES

With the increase in mechanization, the incidence of intra-abdominal injury is increasing. Bleeding, contamination or impairment of function of an intra-abdominal organ must be diagnosed early and dealt with immediately. Serial determination of hemoglobin and cell volume of the blood are useful diagnostic procedures.The older teachings of waiting for a patient to recover from shock before operating are to be decried. Immediate operative intervention to close a ruptured stomach, bowel or bladder, or to suture or remove may be necessary to save the life of the patient.     

A diagnosis of pneumococcal peritonitis secondary to pyo-salpinx in a young healthy female by culturing peritoneal pus

Pneumococcal intra-abdominal infections of female genital tract origin are rare. A 33-year-old woman with peritonitis due to Streptococcus pneumoniae serotype 3 was reported. The patient did not have any of the known predisposing conditions for intra-abdominal pneumococcal infection. The clinical presentation included signs of multiorgan failure. Peritoneal toilette, bilateral salpingectomy and antibiotic treatment were promptly administered. The patient remained febrile, developed respiratory failure and required a repeated laparotomy and a prolonged antimicrobial treatment. Penicillin susceptible S. pneumoniae was isolated from the pus collected at surgery. Thus, culturing of intra-operative specimens should never be neglected to establish the correct microbiologic diagnosis.     

Rupture of the gastrointestinal tract; dealing with lesions caused by non-penetrating trauma

The possibility of rupture of the gastrointestinal tract should be considered in every case of abdominal trauma, and the patient should be carefully observed for a period of 12 to 48 hours. There are many factors that may confuse diagnosis, but in the presence of persistent pain and tenderness, persistent or recurring shock, fever, leukocytosis, roentgen demonstration of free intra-abdominal air, or of other signs of peritonitis, operation should be carried out. The mortality rate is much higher when definitive treatment is delayed more than 12 hours.     

RUPTURE OF THE GASTROINTESTINAL TRACT—Dealing with Lesions Caused by Non-Penetrating Trauma

The possibility of rupture of the gastrointestinal tract should be considered in every case of abdominal trauma, and the patient should be carefully observed for a period of 12 to 48 hours. There are many factors that may confuse diagnosis, but in the presence of persistent pain and tenderness, persistent or recurring shock, fever, leukocytosis, roentgen demonstration of free intra-abdominal air, or of other signs of peritonitis, operation should be carried out. The mortality rate is much higher when definitive treatment is delayed more than 12 hours.     

The Management of Abdominal Injuries in the Presence of Head Injury

When head and blunt abdominal injuries are combined, the head injury is often afforded too much attention and the abdominal injury too little, especially when the patient is unconscious. If mismanaged, the abdominal injury is often the more serious threat to life. Except for extradural hemorrhage, neurosurgical intervention, when indicated, can be delayed until the patient has been thoroughly evaluated for the presence of extra cranial injuries with higher therapeutic priority.Abdominal examination of the unconscious or uncooperative patient is difficult. Tenderness as a sign of abdominal injury cannot be elicited. Abdominal rigidity (in the absence of rigid extremities), a silent abdomen, shock, and extreme restlessness may indicate intra-abdominal changes. Abdominal paracentesis is a valuable diagnostic aid, and the finding of blood, bile-stained fluid, intestinal contents or air is an indication for immediate laparotomy. Once all injuries are known, priorities for treatment can be assigned. Often head and abdominal injuries can be treated concomitantly.     

Gastrointestinal manifestations of diabetic ketoacidosis

The evaluation of gastrointestinal symptoms in patients with diabetic acidosis frequently challenges the physician's clinical acumen. Faced with a seriously ill patient, he must judge whether the abdominal pain, nausea, or vomiting are a consequence of the metabolic decompensation, and hence likely to resolve with correction of the ketoacidosis, or if these symptoms signal a serious underlying intra-abdominal process (e.g., cholecystitis, appendicitis, etc.) which may have precipitated the development of ketoacidosis. The pathogenesis of the reversible gastrointestinal symptoms which frequently accompany diabetic acidosis has not been rigorously defined and may be multifactorial, involving metabolic, humoral, and neural processes. Careful attention to the medical history and abdominal examination greatly facilitates distinguishing patients with intra-abdominal pathology from those with reversible symptoms secondary to ketoacidosis. Similarly, the judicious use of laboratory tests (electrocardiography, blood counts, urinalysis, serum enzyme profile, and abdominal roentgenograms) materially aids in differential diagnosis. Finally, clinical suspicion of an acute abdominal process should prompt early surgical consultation and, if required, surgical intervention as the acidosis is being brought under control.     

Failure to detect intra-abdominal metastases from breast cancer: a case for staging laparotomy

Two studies were performed to assess the accuracy of non-invasive methods in detecting intra-abdominal metastases from breast cancer. Firstly, the sites of spread detected at the time of first presentation with metastases were compared with the sites of spread shown at necropsy in the same patients. Although about two-thirds of the patients with bone and lung metastases at necropsy had had metastases detected at these sites when they first presented with metastases, only a third of the patients with liver metastases and none of those with other intra-abdominal metastases had had evidence of disease at first presentation with metastases. The second study confirmed a poor detection rate of liver and other intra-abdominal metastases in patients with breast cancer undergoing laparotomy and oophorectomy who were staged immediately before operation.Pre-mastectomy staging laparotomy should be considered in those patients with primary breast cancer who are most likely to have disseminated disease beyond the regional nodes. In the presence of occult gross metastases detected by staging laparotomy, mastectomy will not provide additional protection against loca recurrence of disease. Patients with occult gross metastases should also be excluded from studies on adjuvant chemotherapy (designed to treat micrometastases). Aggressive methods of staging are justified to protect the patient as far as possible against unnecessary mastectomy and to identify those patients who should be treated by therapeutic chemotherapy rather than adjuvant chemotherapy.     

Intra-abdominal Cryptococcosis by Cryptococcus gattii: Case Report and Review

Although abdominal cryptococcomas and visceral cryptococcal lymphadenitis as part of disseminated fungal infection have been reported mostly in HIV-infected patients, localized intra-abdominal involvement due to Cryptococcus gattii has not been previously described in non-HIV-infected patients. In general, a smaller proportion of cryptococcosis is caused by C. gattii. We report here on a type II diabetic HIV-negative patient who presented with a localized intra-abdominal cryptococcal mass due to C. gattii. In addition, we review the general aspects of intra-abdominal and gastrointestinal involvement by Cryptococcus neoformans in the literature and discuss the importance of identifying the C. neoformans varieties and C. gattii in routine laboratories.     

Successful antimicrobial therapy of hepatic,intra-abdominal and intrapelvic abscesses.

Antimicrobial therapy without surgical drainage or therapeutic aspiration was effective in the management of four patients with deep abscesses ranging in diameter from 1.3 to 10.0 cm. Two of the patients had multiple hepatic abscesses, one had hepatic, intra-abdominal and intrapelvic abscesses, and one had an intrapelvic abscess alone. Anaerobic bacteria were isolated from the blood or abscesses in all four patients, and an aerobic-anaerobic infection was present in one patient. The patients were treated with metronidazole, alone or in combination with other antibiotics, for 3 to 6 weeks. Therefore, in selected patients with deep abscesses, a therapeutic trial of antimicrobial agents instead of surgery may be justified.     

ROENTGEN DIAGNOSIS OF INTRA-ABDOMINAL HERNIA

The primary radiologic evidence of intra-abdominal hernia is disturbance of normal small intestine arrangement. Loops of intestine are crowded together as if in a bag, giving the appearance of clumping or sacculation. Dilatation and loss of mobility may occur with varying degrees of stasis. Displacement of viscera or pressure deformity may be observed.Studies of the small bowel are necessary to demonstrate these conditions and must be made with the patient in the erect as well as the horizontal position. Repeated studies may be required, and the best time to make them is during an acute attack, as the hernia may be temporarily reduced during a remission.The clinical symptoms are sufficiently characteristic to suggest the diagnosis in most cases. The usual history is of repeated attacks of abdominal pain or discomfort, usually accompanied by distention, varying in periodicity and intensity, with or without nausea or vomiting, and not accompanied by laboratory data or clinical signs indicative of inflammatory disease.Similar or identical clinical and roentgenologic evidence may be produced by torsion of the small bowel or by peritoneal adhesions.The hernia or torsion may reduce spontaneously before or at the time of operation. Therefore, a careful search for abnormal fossae, mesenteric defects or adhesive bands is necessary if herniation or torsion is not found.     

Diabetes and abdominal surgery: the mutual risks

The patient with diabetes represents to the surgeon a particular challenge in the management of acute abdominal problems. In addition to their ongoing and potential metabolic problems, diabetics have specific difficulty in their ability to handle infections and heal wounds. The present report reviews the general principles in the peri-operative management of diabetics and discusses the implications in the diabetic of several specific clinical problems. In view of the known accelerated atherosclerosis associated with diabetes, the risks of anesthesia and surgery must be assessed in the context of the coronary, cerebral, visceral, and peripheral vascular status. Infections in diabetics (potential or established) must be treated aggressively and promptly. Acidosis in the diabetic with abdominal pain must be considered both a metabolic problem and a possible secondary manifestation of an intra-abdominal process. In view of these challenges, the need for careful, anticipatory management of the diabetic patient facing major abdominal surgery is clear.     

Combined Surgical Approach to Young Adults with Hip Dysplasia and Concomitant Intra-Articular Pathology Using Intra-Abdominal Monitoring

BackgroundCombined hip arthroscopy and periacetabular osteotomy (PAO) allows for treatment of intra-articular hip pathology with simultaneous correction of acetabular version and femoral head coverage in patients with symptomatic hip dysplasia. Currently, scant data is available to surgeons regarding optimal technique, sequence of repair, perioperative management, and the use of intra-abdominal monitoring in patients undergoing these combined procedures. The purpose of this study is to describe a two-surgeon, muscle-sparing, approach for sequential hip arthroscopy and PAO for the treatment of adults with acetabular dysplasia and concomitant intra-articular hip pathology.MethodsIn this article, we present the indications for combined hip arthroscopy and PAO, in addition to patient set-up and positioning. A detailed discussion of hip arthroscopy and a muscle sparing PAO techniques are then presented, with overview of a novel intra-abdominal pressure monitoring technique and post-operative rehabilitation protocol.ResultsThrough technical refinement and experience, our indications and protocol for the treatment of patients with symptomatic acetabular dysplasia with concomitant intra-articular hip pathology involves a refined and reproducible, two surgeon procedure utilizing hip arthroscopy followed by PAO. The use of intra-abdominal monitoring allows for assessment of intra-peritoneal pressures to monitor for the development of abdominal compartment syndrome secondary to fluid extravasation.ConclusionThe performance of concomitant hip arthroscopy and PAO for concurrent hip dysplasia and intra-articular hip pathology represents an increasingly common approach in hip preservation surgery. The hip arthroscopy and muscle-sparing PAO protocol using intra-abdominal monitoring described here serves to further refine and advance the indications and technical aspects of this challenging procedure.Level of Evidence: V     

Abdominal aortic aneurysm. Incidence in a hospital population at risk.

The incidence of abdominal aortic aneurysms has been studied in various selected patient groups. In this study, 100 male patients on a cardiology service who were older than 60 years and over 170 cm (5 ft 7 in) tall were examined by abdominal ultrasonograms. A total of 11 aneurysms were found, 2 of which were more than 4.5 cm in diameter. Other abnormalities that were found included renal disease in 20 patients (1 carcinoma treated with a curative nephrectomy), gallbladder disease in 22 patients, and miscellaneous intra-abdominal disease in 6 patients; 47 patients had no abnormalities found. The aneurysms of these patients were classified by a patient''s height in 5-cm (2-in) increments. No significant difference in the incidence of aneurysms was found within the groups, but these groups are small and a significant difference would not be expected. It is of interest that the two large aneurysms were in persons taller than 180 cm (5 ft 11 in). Previous ultrasonographic studies of aneurysmal incidence have not reported other intra-abdominal disease.     

The Incidence,Clinical Outcomes,and Risk Factors of Thrombocytopenia in Intra-Abdominal Infection Patients: A Retrospective Cohort Study

Background

Studies on the incidence and risk factors of thrombocytopenia among intra-abdominal infection patients remain absent, hindering efficacy assessments regarding thrombocytopenia prevention strategies.

Methods

We retrospectively studied 267 consecutively enrolled patients with intra-abdominal infections. Occurrence of thrombocytopenia was scanned for all patients. All-cause 28-day mortality was recorded. Variables from univariate analyses that were associated with occurrence of hospital-acquired thrombocytopenia were included in a multivariable logistic regression analysis to determine thrombocytopenia predictors.

Results

Median APACHE II score and SOFA score of the whole cohort was 12 and 3 respectively. The overall ICU mortality was 7.87% and the 28-day mortality was 8.98%. The incidence of thrombocytopenia among intra-abdominal infection patients was 21.73%. Regardless of preexisting or hospital-acquired one, thrombocytopenia is associated with an increased ICU mortality and 28-day mortality as well as length of ICU or hospital stay. A higher SOFA and ISTH score at admission were significant hospital-acquired thrombocytopenia risk factors.

Conclusions

This is the first study to identify a high incidence of thrombocytopenia in patients with intra-abdominal infections. Our findings suggest that the inflammatory milieu of intra-abdominal infections may uniquely predispose those patients to thrombocytopenia. More effective thrombocytopenia prevention strategies are necessary in intra-abdominal infection patients.     

Obesity: new insight into the anthropometric classification of fat distribution shown by computed tomography.

Twenty eight women presenting for routine computed tomography had their waist, hip, and thigh circumferences measured. The ratio of the area of intra-abdominal fat to the area of subcutaneous fat shown in the computed tomogram taken at the umbilical level was calculated and found to correlate highly significantly with the ratio of waist to hip circumference. The correlation between these two ratios remained significant after allowing for the degree of obesity (weight (kg)/height (m)2) and age. In contrast, there was no significant correlation between the ratio of intra-abdominal to subcutaneous fat and degree of obesity. A high ratio of waist to hip circumference has been shown to be associated with a high proportion of intra-abdominal fat. Thus women with a centralised distribution of fat (high waist to hip ratio: "apples") tend to have a greater proportion of their fat in the intra-abdominal depot than do women with a peripheral fat distribution (low waist to hip ratio: "pears"). The metabolic complications of obesity, which are associated with a high ratio of waist to hip circumference, may therefore relate specifically to the amount of intra-abdominal fat.     

Estrogen improved metabolic syndrome through down-regulation of VEGF and HIF-1α to inhibit hypoxia of periaortic and intra-abdominal fat in ovariectomized female rats

Metabolic syndrome (MBS), a cluster of metabolic abnormalities and visceral fat accumulation, increases cardiovascular risks in postmenopausal women. In addition to visceral fat, perivascular adipose tissue has been recently found to play an important role in vascular pathophysiology. Hence, the present study investigates the effects of estrogen on both intra-abdominal fat (visceral fat) and periaortic fat (perivascular fat) accumulation as well as hypoxia in ovariectomized female rats. Female rats were divided into sham operation, ovariectomy and ovariectomy with 17β-estradiol supplementation groups. Twelve weeks later, we found that estrogen improved MBS via reducing body weight gain, the weight of periaortic and intra-abdominal fat, hepatic triglyceride, and total serum cholesterol levels. Estrogen also increased insulin sensitivity through restoring glucose and serum leptin levels. For periaortic fat, western blot showed estrogen inhibited hypoxia by reducing the levels of VEGF and HIF-1α, which is consistent with the results from immunohistochemical staining. The correlation analysis indicated that perivascular fat had a positive correlation with body weight, intra-abdominal fat or serum total cholesterol, but a negative correlation with insulin sensitivity index. For intra-abdominal fat, real-time fluorescent RT-PCR showed estrogen improved fat dysfunction via reducing the levels of relative leptin, MCP-1 but increasing adiponectin mRNA. Estrogen reduced the levels of VEGF and HIF-1α to inhibit hypoxia but restored the levels of PPARγ and Srebp-1c, which are important for lipid capacity function of intra-abdominal fat. These results demonstrated estrogen improved MBS through down-regulating VEGF and HIF-1α to inhibit hypoxia of periaortic and intra-abdominal fat in ovariectomized female rats.     

Depot-specific effects of early growth retardation on adipocyte insulin action.

Male offspring of rats protein restricted during pregnancy and lactation are growth restricted and have changes in insulin action on epididymal adipocytes. Adipocytes from different anatomical depots are thought to have distinct metabolic functions. The aim of the present study was to determine whether the alterations in metabolism of adipocytes from early growth restricted rats is depot-specific or more generalised. Epididymal, intra-abdominal and subcutaneous adipocytes were studied from three-month-old male offspring of control and protein restricted dams. Basal glucose uptakes were higher in low protein adipocytes (p<0.01) compared to controls. However, insulin stimulation was less in the low protein group in all depots compared to controls (p<0.05). Isoproterenol-stimulated lipolysis was greater in low protein adipocytes (p<0.0001), but the magnitude was greater in epididymal (p<0.0001) and intra-abdominal (p<0.0001) adipocytes than in subcutaneous adipocytes. Epididymal and intra-abdominal adipocytes from low protein offspring were also resistant to the anti-lipolytic action of insulin. These results suggest that certain changes associated with early growth retardation are depot-specific, being enhanced in the more metabolically active intra-abdominal and epididymal tissues.     

Reconstruction of disruption of the abdominal wall in burn patients

Two patients with extensive destruction of the full thickness of the abdominal wall and associated intra-abdominal injuries were encountered. One case resulted from burns to a patient pinned under an automobile in contact with the muffler; the other was injured as a result of penetration of the abdominal wall by a railroad coupling and was also burned in an associated welding accident at the same time. Extensive staged debridement and repair of intra-abdominal injuries in several procedures were required in case 1. Closure was eventually achieved with serial applications of mesh and split-thickness autografting. In case 2, an initial attempt at flap closure failed. Coverage initially was obtained with silicone mesh followed by split-thickness grafting. We report successful management of two of these difficult reconstructive challenges.     

Effect of exercise training on in vivo lipolysis in intra-abdominal adipose tissue in rats

Intra-abdominal obesity is associated with cardiovascular disease and non-insulin-dependent diabetes mellitus, and physical training has been suggested to alleviate these conditions. We compared epinephrine-stimulated lipolysis in vivo in three intra-abdominal adipose tissues (ATs: retroperitoneal, parametrial, and mesenteric) and in subcutaneous AT, and we also studied the effect of physical training. Moreover, we studied the effect of physical training on epinephrine-stimulated lipolysis in muscle in vivo. Female rats were either swim trained (15 wk, n = 8) or sedentary (n = 7). Under anesthesia, a two-stage intravenous epinephrine infusion (60 min of 80 and 200 ng. kg(-1). min(-1), respectively) was carried out, and local interstitial glycerol concentration was measured by the microdialysis technique. Blood flow was measured by microspheres. Training increased blood flow in all ATs [on average: 73 +/- 12 (trained) vs. 14 +/- 4 (sedentary) ml. 100 g(-1). min(-1), P < 0. 05]; nevertheless, epinephrine-stimulated interstitial glycerol concentrations were increased or unchanged. Interstitial glycerol concentration was higher in intra-abdominal than in subcutaneous AT in both trained and sedentary rats. In skeletal muscle, interstitial glycerol concentration and blood flow did not differ between trained and sedentary rats. In conclusion, in vivo lipolysis is higher both in the basal state and during epinephrine-stimulation in intra-abdominal than in subcutaneous AT, and training may be beneficial in alleviating intra-abdominal obesity by enhancing lipolysis in intra-abdominal fat depots.     

Spontaneous splenic rupture in patient with metastatic melanoma treated with vemurafenib

ABSTRACT: BACKGROUND: BRAF inhibitors such as vemurafenib are a new family of biological drugs, recently available to treat metastatic malignant melanoma. METHODS: We present the case of a 38-year-old man affected by metastatic melanoma who had been under treatment with vemurafenib for a few days. The patient suffered from sudden onset of abdominal pain due to intra-abdominal hemorrhage with profuse hemoperitoneum. An emergency abdominal sonography confirmed the clinical suspicion of a splenic rupture. RESULTS: The intraoperative finding was hemoperitoneum due to splenic two-step rupture and splenectomy was therefore performed. Histopathology confirmed splenic hematoma and capsule laceration, in the absence of metastasis. CONCLUSIONS: This report describes the occurrence of a previously unreported adverse event in a patient with stage IV melanoma receiving vemurafenib.