Identifying the bleeding trauma patient: predictive factors for massive transfusion in an Australasian trauma population.

PubMed

Hsu, Jeremy Ming; Hitos, Kerry; Fletcher, John P

2013-09-01

Military and civilian data would suggest that hemostatic resuscitation results in improved outcomes for exsanguinating patients. However, identification of those patients who are at risk of significant hemorrhage is not clearly defined. We attempted to identify factors that would predict the need for massive transfusion (MT) in an Australasian trauma population, by comparing those trauma patients who did receive massive transfusion with those who did not. Between 1985 and 2010, 1,686 trauma patients receiving at least 1 U of packed red blood cells were identified from our prospectively maintained trauma registry. Demographic, physiologic, laboratory, injury, and outcome variables were reviewed. Univariate analysis determined significant factors between those who received MT and those who did not. A predictive multivariate logistic regression model with backward conditional stepwise elimination was used for MT risk. Statistical analysis was performed using SPSS PASW. MT patients had a higher pulse rate, lower Glasgow Coma Scale (GCS) score, lower systolic blood pressure, lower hemoglobin level, higher Injury Severity Score (ISS), higher international normalized ratio (INR), and longer stay. Initial logistic regression identified base deficit (BD), INR, and hemoperitoneum at laparotomy as independent predictive variables. After assigning cutoff points of BD being greater than 5 and an INR of 1.5 or greater, a further model was created. A BD greater than 5 and either INR of 1.5 or greater or hemoperitoneum was associated with 51 times increase in MT risk (odds ratio, 51.6; 95% confidence interval, 24.9-95.8). The area under the receiver operating characteristic curve for the model was 0.859. From this study, a combination of BD, INR, and hemoperitoneum has demonstrated good predictability for MT. This tool may assist in the determination of those patients who might benefit from hemostatic resuscitation. Prognostic study, level III.

Positive FAST without hemoperitoneum due to fluid resuscitation in blunt trauma.

PubMed

Slutzman, Jonathan E; Arvold, Lisa A; Rempell, Joshua S; Stone, Michael B; Kimberly, Heidi H

2014-10-01

The focused assessment with sonography in trauma (FAST) examination is an important screening tool in the evaluation of blunt trauma patients. To describe a case of a hemodynamically unstable polytrauma patient with positive FAST due to fluid resuscitation after blunt trauma. We describe a case of a hemodynamically unstable polytrauma patient who underwent massive volume resuscitation prior to transfer from a community hospital to a trauma center. On arrival at the receiving institution, the FAST examination was positive for free intraperitoneal fluid, but no hemoperitoneum or significant intra-abdominal injuries were found during laparotomy. In this case, it is postulated that transudative intraperitoneal fluid secondary to massive volume resuscitation resulted in a positive FAST examination. This case highlights potential issues specific to resuscitated trauma patients with prolonged transport times. Further study is likely needed to assess what changes, if any, should be made in algorithms to address the effect of prior resuscitative efforts on the test characteristics of the FAST examination. Copyright © 2014 Elsevier Inc. All rights reserved.

Massive spontaneous hemoperitoneum due to rupture of visceral branches of the abdominal aorta.

PubMed

Pollak, E W; Michas, C A

1979-10-01

Review of 153 cases of massive spontaneous hemoperitoneum following visceral arterial rupture showed that 94% of all young women and 100% of all pregnant women had ruptured congenital splenic artery aneurysms at the time of hemorrhage, whereas young males bled from a variety of sources. Individuals who were 45 years old or older bled either from lesions of the celiac axis or its branches (66%) or from arterial mesenteric system lesions (34%). Only 22% of the older individuals of either sex bled from splenic artery sources. Arterial hypertension was present in 40% and previous or simultaneous intracranial hemorrhage occurred in 9% of the older patients. There were no survivors among those in whom the bleeding source was not operatively controlled. With operation, 79% of the younger patients and 57% of the older ones survived. Results emphasize the high mortality of visceral artery rupture with intraperitoneal bleeding. Prophylactic excision is advised for all complicated aneurysms regardless of age and all uncomplicated aneurysms in healthy individuals, especially in fertile or pregnent women.

Hemothorax caused by spontaneous rupture of hepatocellular carcinoma: a case report and review of the literature.

PubMed

Ono, Fuminori; Hiraga, Masaki; Omura, Noriyuki; Sato, Manabu; Yamamura, Akihiro; Obara, Megumi; Sato, Jun; Onochi, Shoichi

2012-10-10

We report a rare case in which hemothorax occurred in addition to hemoperitoneum due to spontaneous rupture of hepatocellular carcinoma (HCC) originating from the caudate lobe of the liver. The case pertains to a 56-year-old female who was transported to our hospital for impaired consciousness due to hemorrhagic shock. Computed tomography (CT) demonstrated ruptured HCC originating from the caudate lobe and accompanying hemoperitoneum and right hemothorax. Hemostasis was carried out by transcatheter arterial embolization (TAE), and surgery was conducted approximately one month after TAE. In the present case, no lesions as possible sources of bleeding were observed inside the pleural cavity, and, moreover, the diaphragm had no abnormalities in the intraoperative findings, suggesting that blood from the ruptured tumor may have traversed the intact diaphragm to enter the right pleural cavity soon after the HCC rupture. However, to the best of our knowledge, no similar cases of HCC have been reported to date, and this case is thus believed to be very rare. This unusual phenomenon may therefore be strongly associated with the location of the ruptured tumor and the formation of a hematoma inside the omental bursa. We discuss the mechanism causing hemothorax in the present case and also review the previously reported cases of ruptured HCC complicated by hemothorax.

Hemothorax caused by spontaneous rupture of hepatocellular carcinoma: a case report and review of the literature

PubMed Central

2012-01-01

We report a rare case in which hemothorax occurred in addition to hemoperitoneum due to spontaneous rupture of hepatocellular carcinoma (HCC) originating from the caudate lobe of the liver. The case pertains to a 56-year-old female who was transported to our hospital for impaired consciousness due to hemorrhagic shock. Computed tomography (CT) demonstrated ruptured HCC originating from the caudate lobe and accompanying hemoperitoneum and right hemothorax. Hemostasis was carried out by transcatheter arterial embolization (TAE), and surgery was conducted approximately one month after TAE. In the present case, no lesions as possible sources of bleeding were observed inside the pleural cavity, and, moreover, the diaphragm had no abnormalities in the intraoperative findings, suggesting that blood from the ruptured tumor may have traversed the intact diaphragm to enter the right pleural cavity soon after the HCC rupture. However, to the best of our knowledge, no similar cases of HCC have been reported to date, and this case is thus believed to be very rare. This unusual phenomenon may therefore be strongly associated with the location of the ruptured tumor and the formation of a hematoma inside the omental bursa. We discuss the mechanism causing hemothorax in the present case and also review the previously reported cases of ruptured HCC complicated by hemothorax. PMID:23046863

A fatal case of hemoperitoneum after ultrasound-guided liver biopsy in a patient with intravascular large B-cell lymphoma.

PubMed

Aoki, Yasuhiro; Takamiya, Masataka; Satoh, Takashi; Fujita, Sachiko; Kato, Hideaki; Maeno, Yoshitaka

2011-07-01

An autopsy case of fatal complication of percutaneous liver biopsy targeting a rare type of large B-cell lymphoma is presented. A 79 year-old man was referred to the hematology unit of a hospital because of anemia with thrombocytopenia and hepatosplenomegaly. Results of inguinal lymph node biopsy were inconclusive. To investigate a mass lesion in the liver visualized by ultrasonography, image-guided liver biopsy was performed following platelet infusion. The patient became unresponsive 6h post procedure because of hypotension due to intraperitoneal hemorrhage of undetermined origin. Autopsy revealed hemoperitoneum but failed to identify any macroscopic intra- or extrahepatic vascular injuries. Histopathological investigation disclosed infiltration of atypical lymphocytes into the systemic organs including the lymph nodes, spleen, liver, and lungs. Prominent hemophagocytosis was also noted. The lymphoma cells were exclusively accumulated within vascular and sinusoidal structures, and diagnosed with immunohistochemistry as Asian variant of intravascular large B-cell lymphoma. Massive blood extravasation was presumed to originate directly from the markedly dilated liver sinusoids filled with erythrocytes, macrophages and tumor cells, under the condition of impaired hemostasis. Although the biopsy was thought to have been correctly performed, this case would be instructive for evaluation of the indications and risks associated with liver biopsy. 2011 Elsevier Ireland Ltd. All rights reserved.

Spontaneous hemoperitoneum in pregnancy (SHiP) and endometriosis - A systematic review of the recent literature.

PubMed

Lier, Marit C I; Malik, Romana F; Ket, Johannes C F; Lambalk, Cornelis B; Brosens, Ivo A; Mijatovic, Velja

2017-12-01

Spontaneous Hemoperitoneum in Pregnancy (SHiP), an unprovoked (nontraumatic) intraperitoneal bleeding in pregnancy (up to 42days postpartum), is associated with serious adverse pregnancy outcomes. To evaluate the clinical consequences of SHiP and its association with endometriosis, a systematic review was conducted according to the PRISMA guidelines. PubMed, Embase.com and Thomson Reuters/Web of Science were searched for articles published since the latest review (August 2008) until September 2016. After assessment for eligibility, forty-four articles were included in this systematic review, describing 59 cases of SHiP. Endometriosis was present in 33/59 cases (55.9%), most often diagnosed prior to pregnancy. An association between the severity of SHiP and the stage of endometriosis could not be found. In the majority of cases, SHiP occurred in the third trimester of pregnancy (30/59 cases (50.8%)); women presented with (sub)acute abdominal pain (56/59 cases (94.9%)), hypovolemic shock (28/59 cases (47.5%)) and/or a decreased level of hemoglobin (37/59 cases (62.7%)). Signs of fetal distress were observed in 24/59 cases (40.7%). Imaging confirmed free peritoneal fluid in (37/59 cases (62.7%)). At time of surgery active bleeding was revealed in 51/56 cases (91,1%), originating from endometriotic implants (11/51 cases (21.6%)), ruptured utero-ovarian vessels (29/51 cases (56.8%)), hemorrhagic nodules of decidualized cells (1/51 cases (2.0%)) or a combination (10/51 cases (19.6%)). Median amount of hemoperitoneum was 1600mL (IQR 1000mL-2500mL). From the 45/59 cases (76.3%) in which surgical interventions was carried out during pregnancy, 7/45 cases (15.6%) reported a successful continuation of pregnancy. 5/59 cases reported recurrence of SHiP (recurrence rate 8.5%). The perinatal mortality rate was 26.9% (18/67 fetus), one maternal death was reported (1/59 cases (1,7%)). In conclusion, SHiP is a very serious complication of pregnancy, highly associated with adverse pregnancy outcomes and particularly relevant to women with endometriosis. Currently preventive measures are lacking, therefore increasing the awareness and recognition of SHiP is crucial to improve pregnancy outcomes. Copyright © 2017 Elsevier B.V. All rights reserved.

Delayed splenic vascular injury after nonoperative management of blunt splenic trauma.

PubMed

Furlan, Alessandro; Tublin, Mitchell E; Rees, Mitchell A; Nicholas, Dederia H; Sperry, Jason L; Alarcon, Louis H

2017-05-01

Delayed splenic vascular injury (DSVI) is traditionally considered a rare, often clinically occult, harbinger of splenic rupture in patients with splenic trauma that are managed conservatively. The purpose of our study was to assess the incidence of DSVI and associated features in patients admitted with blunt splenic trauma and managed nonoperatively. A retrospective analysis was conducted over a 4-y time. Patients admitted with blunt splenic trauma, managed no-operatively and with a follow-up contrast-enhanced computed tomography (CT) scan study during admission were included. The CT scans were reviewed for American Association for the Surgery of Trauma splenic injury score, amount of hemoperitoneum, and presence of DSVI. Logistic regression models were used to investigate the risk factors associated with DSVI. A total of 100 patients (60 men and 40 women) constituted the study group. Follow-up CT scan demonstrated a 23% incidence of DSVI. Splenic artery angiography validated DSVI in 15% of the total patient population. Most DSVIs were detected only on arterial phase CT scan imaging. The American Association for the Surgery of Trauma splenic injury score (odds ratio = 1.73; P = 0.045) and the amount of hemoperitoneum (odds ratio = 1.90; P = 0.023) on admission CT scan were associated with the development of DSVI on follow-up CT scan. DSVI on follow-up CT scan imaging of patients managed nonoperatively after splenic injury is common and associated with splenic injury score assessed on admission CT scan. Copyright © 2016 Elsevier Inc. All rights reserved.

Population-based study on the effect of socioeconomic factors and race on management and outcomes of 35,535 inpatient ectopic pregnancies.

PubMed

Papillon-Smith, Jessica; Imam, Basel; Patenaude, Valerie; Abenhaim, Haim Arie

2014-01-01

To evaluate whether socioeconomic variables influence the management and outcomes of ectopic pregnancies. Retrospective cohort study (Canadian Task Force classification II-2). Hospitals in the United States participating in the Health Care Cost and Utilization Project. Women (n = 35 535) with a primary discharge diagnosis of ectopic pregnancy. Effect of socioeconomic factors and race/ethnicity on management and adverse outcomes of ectopic pregnancy. During the 9-year study, 35 535 ectopic pregnancies were identified. The development of hemoperitoneum in 8706 patients (24.50%) was the most common complication. Asian race was the sociodemographic variable most predictive of hemoperitoneum (odds ratio [OR], 1.41; 95% confidence interval [CI], 1.24-1.61; p < .01) and transfusion (OR, 1.62; 95% CI, 1.39-1.89; p < .01), and Medicare status was most influential on prolonged hospitalization (OR, 1.83; 95% CI, 1.36-2.47; p < .01). Major complications were not affected by socioeconomic factors. Laparotomy in 25 075 patients (70.6%) was the most common treatment option. Patients of Asian or Pacific Islander descent were least likely to be treated non-surgically (OR, 0.62; 95% CI, 0.51-0.76; p < .01), whereas Medicare recipients were most likely to be treated non-surgically (OR, 1.70; 95% CI, 1.32-2.18; p < .01). All non-white groups were less likely to undergo a laparoscopic approach. Major complications from ectopic pregnancy are not influenced by socioeconomic variables; however, less serious complications and management approaches are persistently affected. Copyright © 2014 AAGL. Published by Elsevier Inc. All rights reserved.

An Autopsy Case of a Pregnant Woman With Severe Placental and Fetal Damage From Domestic Violence.

PubMed

Kanawaku, Yoshimasa; Takahashi, Shirushi; Kanetake, Jun; Funayama, Masato

2015-09-01

We present an autopsy case of a pregnant woman who was a victim of domestic violence. The deceased showed injuries mainly to her head and abdomen. Postmortem examination revealed 1400 mL of abdominal hemorrhage, ablation of the perimetrium, placental avulsion, and intracranial hematoma. The cause of death was diagnosed as hemorrhagic shock. The uterus contained a fetus of 7 months' gestational age. Fetal autopsy revealed laceration of the lungs, laceration and avulsion of the liver, and 15 mL of hemoperitoneum. Both placental and fetal injuries suggested repeated severe attacks to the abdomen, such as those expected to result from kicking or hitting.

Spontaneous rectus sheath hematoma presenting as acute surgical abdomen: an important differential in elderly coagulopathic patients.

PubMed

Salemis, Nikolaos S

2009-06-01

Rectus sheath hematoma (RSH) presenting as acute surgical abdomen is a rare clinical entity. Failing to establish an early diagnosis will probably result in increased morbidity or unnecessary surgical intervention. We describe herein a case of an 85-year-old woman receiving anticoagulants who presented with typical clinical manifestations of acute surgical abdomen and a slightly palpable abdominal mass. Ultrasonography was inconclusive whereas computed tomography scans demonstrated a large right rectus sheath hematoma associated with hemoperitoneum. The patient was treated conservatively with success. It is therefore concluded that RSH must be considered in any elderly patient on anticoagulant therapy who presents with manifestations of acute surgical abdomen.

Fatal Liver Cyst Rupture Due to Anabolic Steroid Use: A Case Presentation.

PubMed

Hansma, Patrick; Diaz, Francisco J; Njiwaji, Chantel

2016-03-01

Liver cysts are commonly found incidentally from imaging scans or at autopsy. These benign neoplasms vary in size and represent a heterogeneous group of disorders, for which the demographics, risk factors, apparent inciting event, clinical presentation, and outcome are varied. Complications that can develop from a liver cyst include development of spontaneous hemorrhage, infection, and/or obstruction. Although the etiology of liver cysts varies, fatal rupture of a hemorrhagic liver cyst due to anabolic steroid use is a rare occurrence. In fact, there are few reported cases in journal literature. We report a case of a fatal liver cyst rupture with resultant hemoperitoneum in the presence of anabolic steroid (stanozolol) use.

Assessment of the relationships among coagulopathy, hyperfibrinolysis, plasma lactate, and protein C in dogs with spontaneous hemoperitoneum.

PubMed

Fletcher, Daniel J; Rozanski, Elizabeth A; Brainard, Benjamin M; de Laforcade, Armelle M; Brooks, Marjory B

2016-01-01

To relate coagulation and fibrinolysis derangements to shock severity as reflected by plasma lactate concentrations in dogs with spontaneous hemoperitoneum (SHP) and determine the impact on transfusions. Prospective, observational, case-control study. Three veterinary teaching hospitals. Twenty-eight client-owned dogs with SHP and 28 breed- and age-matched control dogs. None. Blood samples for platelet counts, coagulation, and anticoagulant assays (prothrombin time, activated partial thromboplastin time, fibrinogen, antithrombin, and protein C, thromboelastography [TEG]), fibrinolysis testing (d-dimer and TEG lysis parameters with and without the addition of 50 U/mL of tissue plasminogen activator [TEG LY30 measured with the addition of 50 U/mL of tPA to the blood sample, LY3050 and TEG LY60 measured with the addition of 50 U/mL of tPA to the blood sample, LY6050 ; LY30 and LY60]), and plasma lactate as an indicator of severity of shock were collected from SHP dogs at the time of diagnosis. SHP dogs were hypocoagulable (prolonged prothrombin time and activated partial thromboplastin time, decreased TEG maximum amplitude) and hyperfibrinolytic (increased LY3050 and TEG LY6050 ) compared to controls. The severity of hypocoagulability was related to protein C activity, while the severity of hyperfibrinolysis was related to plasma lactate concentration. Among the 18 dogs discharged from the hospital, LY3050 was significantly associated with the dose of fresh frozen plasma administered, but none of the parameters were associated with the dose of red blood cells administered. Dogs with SHP have evidence of hypocoagulability, protein C deficiency, and hyperfibrinolysis. Parameters of hyperfibrinolysis were related to plasma lactate concentrations and volume of plasma transfused during hospitalization. These derangements resemble those found in people with acute coagulopathy of trauma and shock, and activation of protein C may be a common feature to both syndromes. © Veterinary Emergency and Critical Care Society 2015.

Management of pediatric blunt splenic injury at a rural trauma center.

PubMed

Bird, Julio J; Patel, Nirav Y; Mathiason, Michelle A; Schroeppel, Thomas J; D'huyvetter, Cecile J; Cogbill, Thomas H

2012-10-01

Patterns for nonoperative management of pediatric blunt splenic injuries (BSIs) vary significantly within and between institutions. The indications for repeated imaging, duration of activity restrictions, as well as the impact of volume and type of trauma center (pediatric vs. adult) on outcomes remain unclear. A retrospective review of all patients younger than 16 years with BSI managed at a rural American College of Surgeons-verified adult Level II trauma center from January 1995 to December 2008 was completed. Patients were identified from the trauma registry by DRG International Classification of Diseases-9th Rev. (865.00-865.09) and management codes (41.5, 41.43, and 41.95). Variables reviewed included demographics, mechanism of injury, Injury Severity Score, grade of splenic injury, degree of hemoperitoneum, presence of arterial phase contrast blush on computed tomography at admission, admission and nadir hemoglobin level, blood transfused, length of stay, disposition, outpatient clinical and radiographic follow-up, interval of return to unrestricted activity, and clinical outcomes. During the 13-year study period, 38 children with BSI were identified. Thirty-seven (97%) were successfully managed nonoperatively. Median grade of splenic injury was 3 (range, 1-5); 73% had moderate-to-large hemoperitoneum. Median Injury Severity Score was 10 (range, 4-34). Three patients with isolated contrast blush on initial computed tomography were successfully managed nonoperatively with no angiographic intervention. One patient failed nonoperative management and underwent successful splenorrhaphy. All patients were discharged home. Thirty-day mortality was zero. Median follow-up duration was 5.5 years, with no late complications identified. Of the patients successfully managed nonoperatively, 92% had their follow-up at our institution; 74% underwent subsequent imaging, and none resulted in intervention or alteration of management plan. Pediatric BSI can be managed in adult trauma centers with success rates of nonoperative management comparable to dedicated children's hospitals. Routine follow-up imaging is not necessary. Overall splenic injury salvage rate in our experience was 100%. Therapeutic/epidemiologic study, level IV.

Case studies on second-generation anticoagulant rodenticide toxicities in nontarget species.

PubMed

DuVall, M D; Murphy, M J; Ray, A C; Reagor, J C

1989-01-01

Specimens from 10 cases of second-generation anticoagulant rodenticide poisoning in dogs and cats were submitted to the Texas Veterinary Medical Diagnostic Laboratory during 1986 and 1987. The clinical signs most frequently observed were lethargy, dyspnea, and ventral hematomas; common necropsy findings included hemoperitoneum, hemothorax, and pulmonary hemorrhage. In the instances when histopathological examination of the tissue was done, it supported a diagnosis of coagulopathy. The presence of anticoagulants in serum or liver was confirmed by high pressure liquid chromatography, gas chromatography/mass spectrometry, or a combination of the two. Five cases of brodifacoum poisoning, 2 of bromadiolone, and 3 of diphacinone toxicity were verified. Concentrations of these rodenticides ranged from approximately 0.001 to 12 ppm.

Heterotopic pregnancy following induction of ovulation with clomiphene citrate.

PubMed

Ghandi, Sedigheh; Ahmadi, Raheleh; Fazel, Mahmoud

2011-01-01

Although heterotopic gestation is common in assisted reproductive techniques, it is very rare in natural conception and clomiphene induced pregnancy. Diagnosis and appropriate intervention of heterotopic pregnancy requires a high index of suspicious. In this paper a case of heterotopic pregnancy in a 30-year old woman with hemoperitoneum from ruptured tubal pregnancy with live intrauterine gestation at 9 weeks of gestation is reported. This case suggests that a heterotopic pregnancy must always be considered particularly after the induction of ovulation by clomiphene citrate or assisted reproductive technology. Every clinician treating women of reproductive age should keep this diagnosis in mind. It also demonstrates that early diagnosis is essential in order to salvage the intrauterine pregnancy and avoid maternal morbidity and mortality.

Evaluation of Critical Care Monitor Technology During the US Navy Strong Angel Exercise

NASA Technical Reports Server (NTRS)

Johannesen, John; Rasbury, Jack

2003-01-01

The NASA critical path road map identifies "trauma and acute medical problems" as a clinical capability risk category (http://criticalDath.isc.nasa.gov). Specific risks include major trauma, organ laceration or contusion, hemoperitoneum, pulmonary failure, pneumo- and hemothorax, burn, open bone fracture, blunt head trauma, and penetrating injury. Mitigation of these risks includes the capability for critical care monitoring. Currently, the International Space Station (ISS) Crew Health Care System (CHeCS) does not provide such a capability. The Clinical Space Medicine Strategic Planning Forum (4/8/97), sponsored by NASA Medical Operations, identified the development of trauma care capabilities as one of the top priorities for space medicine. The Clinical Care Capability Development Project (CCCDP) subsequently undertook the task to address this need.

Disseminated gestational choriocarcinoma presenting with hepatic and uveal metastases, hook effect, and choriocarcinoma syndrome.

PubMed

Aswani, Yashant; Thakkar, Hemangini; Hira, Priya

2016-01-01

Choriocarcinoma is a human chorionic gonadotrophin (HCG)-secreting tumor that comprises vascular channels. It has a tendency for widespread metastasis, common sites for which include the lung, vagina, brain, liver, bone, intestine, and kidney. We describe a 30-year-old female who presented with hepatitis-like features and bilateral diminution of vision, and subsequently developed hemothorax and hemoperitoneum-all rare and seemingly unrelated manifestations which were finally attributable to metastases from gestational choriocarcinoma. To further complicate the clinical scenario, the serum HCG of the patient was mildly raised (due to a phenomenon called hook effect). Subsequently, the patient developed disseminated intravascular coagulation and succumbed to her illness. In this report, we discuss the imaging findings of choriocarcinoma, its potential sites of metastases, and the hook effect.

Heterotopic pregnancy following induction of ovulation with clomiphene citrate

PubMed Central

Ghandi, Sedigheh; Ahmadi, Raheleh; Fazel, Mahmoud

2011-01-01

Background: Although heterotopic gestation is common in assisted reproductive techniques, it is very rare in natural conception and clomiphene induced pregnancy. Diagnosis and appropriate intervention of heterotopic pregnancy requires a high index of suspicious. Case: In this paper a case of heterotopic pregnancy in a 30-year old woman with hemoperitoneum from ruptured tubal pregnancy with live intrauterine gestation at 9 weeks of gestation is reported. Conclusion: This case suggests that a heterotopic pregnancy must always be considered particularly after the induction of ovulation by clomiphene citrate or assisted reproductive technology. Every clinician treating women of reproductive age should keep this diagnosis in mind. It also demonstrates that early diagnosis is essential in order to salvage the intrauterine pregnancy and avoid maternal morbidity and mortality. PMID:26396583

Recanalization of Splenic Artery Aneurysm After Transcatheter Arterial Embolization Using N-Butyl Cyanoacrylate

DOE Office of Scientific and Technical Information (OSTI.GOV)

Matsumoto, Keiji; Ushijima, Yasuhiro, E-mail: ushijima@radiol.med.kyushu-u.ac.jp; Tajima, Tsuyoshi

2010-02-15

A 65-year-old woman who had been diagnosed as having microscopic polyangiitis developed sudden abdominal pain and entered a state of shock. Abdominal CT showed massive hemoperitoneum, and emergent angiography revealed a ruptured splenic artery aneurysm. After direct catheterization attempts failed due to tortuous vessels and angiospasm, transcatheter arterial embolization using an n-butyl cyanoacrylate (NBCA)-lipiodol mixture was successfully performed. Fifty days later, the patient developed sudden abdominal pain again. Repeated angiography demonstrated recanalization of the splenic artery and splenic artery aneurysm. This time, the recanalized aneurysm was embolized using metallic coils with the isolation method. Physicians should keep in mind thatmore » recanalization can occur after transcatheter arterial embolization using N-butyl cyanoacrylate, which has been used as a permanent embolic agent.« less

[Rupture of non-communicating rudimentary pregnant uterine horn in a pseudo-unicornuate uterus at 23 weeks of amenorrhea. Case report].

PubMed

Fuchs, F; Guillot, E; Cordier, A-G; Chis, C; Raynal, P; Panel, P

2008-04-01

Pregnancy in the rudimentary horn of a unicornuate uterus is an extremely rare form of ectopic gestation associated with a high risk of uterine rupture. We report the case of a pregnancy developed in a non communicating rudimentary horn of a unicornuate uterus complicated by horn rupture at 23 weeks of amenorrhea showing as an acute abdominal pain and massive hemoperitoneum. This patient's uterine abnormality was known before, as this woman has delivered two years before at term a healthy boy by cesarean section. This past pregnancy was located in the normal horn and the non communicating rudimentary horn seemed at this time normal. This uterine malformation is presented with its gynecological and obstetrical entailments as well as methods that could prevent such outcome.

Laparoscopic treatment of traumatic rupture of hydatid hepatic cyst--is it feasible?: A case report.

PubMed

Feleppa, Cosimo; D'Ambra, Luigi; Berti, Stefano; Magistrelli, Prospero; Sani, Cinzia; Falco, Emilio

2009-08-01

Hydatid disease is endemic in several countries. Although the disease can be asymptomatic for long time, it is usually progressive and insidious and can be even challenging in emergency both for its diagnosis and its treatment. We report the case of an 8-year-old Albanian boy who was admitted in emergency to our surgical department with the diagnosis of suspected hemoperitoneum caused by a mild liver trauma. The abdominal laparoscopic exploration showed, besides peritoneal free serohematic liquid, a ruptured hepatic cystic lesion involving the left liver, which was completely excised. Even if there are not yet any reports about the usefulness of laparoscopic treatment of ruptured liver hydatid cysts, we believe that laparoscopic approach can help the diagnosis and in selected cases, the management of this condition. However more studies need to be carried out to evaluate it's long-term safeness about the recurrence of hydatid disease.

Cola-colored dialysate as a gastrointestinal sequelae of cardiac surgery in a patient who underwent peritoneal dialysis.

PubMed

Ling, Eng-Kian; Lin, Bing-Shi; Chiang, Shou-Shan; Tsai, Ming-Hsien

2012-01-01

The discoloration of effluent peritoneal dialysate, which is transparent in origin, is seen in some particular conditions including chyloperitoneum, calcium channel blocker usage, hemoperitoneum, perforated cholecystitis, iron administration, and hemorrhagic pancreatitis. We report a case of a 60-year-old woman who underwent peritoneal dialysis for 3 years and presented with conspicuous cola-colored (brownish-black) dialysate after a cardiac surgery. The findings of the dialysate analysis and the abdominal computed tomography showed that this discoloration could be due to the presence of methemalbumin caused by pancreatitis (not hemorrhagic) combined with intra-abdominal bleeding-both of which are rare gastrointestinal complications of cardiac surgery. She eventually died of pulseless electrical activity due to severe sepsis with profound shock. Therefore, the rare event of cola-colored peritoneal dialysate could present as severe gastrointestinal sequelae of cardiac surgery and may indicate a poor prognosis.

[The criteria for choose of treatment method of children with spleen injuries].

PubMed

Podkamenev, V V; Pikalo, I A

2014-01-01

It was performed cohort prospective study of treatment results of 69 children with through-capsule spleen injuries for the period from 2002 to 2013. Patients were divided into 2 groups. The first group included 63 patients after non-surgical treatment. The second group included 6 children who underwent surgery. In the first group 95.3% of patients had stable hemodynamics at admission. In the second group only 2 patients had the signs of deferred bleeding. Continuing abdominal bleeding was the indication for surgery in 4 patients although stable hemodynamics. Hemoperitoneum in case of spleen injury is not significant prognostic factor defining the tactics of treatment. The physiological response on bleeding but not the amount of blood in abdominal cavity determines tactics of treatment. Hemodynamic status is single statistically significant criterion for choose of surgical treatment of children with spleen injuries. Unstable hemodynamics increases the risk of surgical treatment in 20 times (p<0.007).

Delayed rupture of gallbladder following blunt abdominal trauma.

PubMed

Mohanty, Debajyoti; Agarwal, Himanshu; Aggarwal, Krittika; Garg, Pankaj Kumar

2014-09-01

A 29-year-old gentleman presented to surgery emergency with severe upper abdominal pain and vomiting. He reported to had been hit in his abdomen by a ball during a cricket match. Computerized tomogram of the abdomen revealed hematoma within the gallbladder lumen, laceration of segment six of liver, and hemoperitoneum. The patient did not agree for laparotomy advised to him, and so, managed conservatively. The patient reported back to us with high grade fever, jaundice, and painful abdominal distension after seven days of discharge from the hospital. His abdominal examination showed features of generalized peritonitis. Surgical abdominal exploration revealed a single perforation in the fundus of gallbladder with frozen calot'striangle. Subtotal cholecystectomy was done. Histopathology of excised gallbladder revealed xanthogranulomatous inflammation. The present case report highlights that early exploration and cholecystectomy should be considered in patients with gallbladder injury to obviate the risk of delayed perforation.

Prognostic Factors for Morbimortality in Sleeve Gastrectomy. The Importance of the Learning Curve. A Spanish-Portuguese Multicenter Study.

PubMed

Sánchez-Santos, Raquel; Corcelles Codina, Ricard; Vilallonga Puy, Ramon; Delgado Rivilla, Salvadora; Ferrer Valls, Jose Vicente; Foncillas Corvinos, Javier; Masdevall Noguera, Carlos; Socas Macias, Maria; Gomes, Pedro; Balague Ponz, Carmen; De Tomas Palacios, Jorge; Ortiz Sebastian, Sergio; Sanchez-Pernaute, Andres; Puche Pla, Jose Julian; Del Castillo Dejardin, Daniel; Abasolo Vega, Julen; Mans Muntwyler, Ester; Garcia Navarro, Ana; Duran Escribano, Carlos; Cassinello Fernández, Norberto; Perez Climent, Nieves; Gracia Solanas, Jose Antonio; Garcia-Moreno Nisa, Francisca; Hernández Matias, Alberto; Valentí Azcarate, Victor; Perez Folques, Jose Eduardo; Navarro Garcia, Inmaculada; Dominguez-Adame Lanuza, Eduardo; Martinez Cortijo, Sagrario; González Fernández, Jesus

2016-12-01

Complications in sleeve gastrectomy (SG) can cast a shadow over the technique's good results and compromise its safety. The aim of this study is to identify risk factors for complications, and especially those that can potentially be modified to improve safety. A retrospective multicenter cohort study was carried out, involving the participation of 29 hospitals. Data was collected on demographic variables, associated comorbidities, technical modifications, the surgeon's experience, and postoperative morbimortality. A multivariate logistic regression analysis was carried out on risk factors (RFs) for the complications of leak/fistula, hemoperitoneum, pneumonia, pulmonary embolism, and death. The following data were collected for 2882 patients: age, 43.85 ± 11.6. 32.9 % male; BMI 47.22 ± 8.79; 46.2 % hypertensive; 29.2 % diabetes2; 18.2 % smokers; bougie calibre ≥40 F 11.1 %; complications 11.7 % (2.8 % leaks, 2.7 % hemoperitoneum, 1.1 % pneumonia, 0.2 % pulmonary embolism); and death 0.6 %. RFs for complications were as follows: surgeon's experience < 20 patients, OR 1.72 (1.32-2.25); experience > 100 patients, OR 0.78 (0.69-0.87); DM2, OR1.48(1.12-1.95); probe > 40 F, OR 0.613 (0.429-0.876). Leak RFs were the following: smoking, OR1.93 (1.1-3.41); surgeon's experience < 20 patients, OR 2.4 (1.46-4.16); experience of 20-50 patients, OR 2.5 (1.3-4.86); experience >100 patients, OR 0.265 (0.11-0.63); distance to pylorus > 4 cm, OR 0.510 (0.29-0.91). RFs for death were as follows: smoking, OR 8.64 (2.63-28.34); DM2, OR 3.25 (1.1-9.99); distance to pylorus < 5 cm, OR 6.62 (1.63-27.02). The safety of SG may be compromised by nonmodifiable factors such as age >65, patient comorbidities (DM2, hypertension), and prior treatment with anticoagulants, as well as by modifiable factors such as smoking, bougie size <40 F, distance to the pylorus <4 cm, and the surgeon's experience (<50-100 cases).

Hemorrhagic shock caused by sigmoid colon volvulus: An autopsy case

PubMed Central

Sato, Hiroaki; Tanaka, Toshiko; Tanaka, Noriyuki

2011-01-01

Summary Background Many reports have described sigmoid volvulus, but fatal hemorrhagic shock resulting from the rupture of the involved artery has not been reported as a complication of a sigmoid volvulus. Case Report A 71-year-old man with slight abdominal pain and obstipation in hypotension died at a nursing home without seeing a doctor. At autopsy, a mesenteric hematoma and hemoperitoneum was observed with approximately 1,000 ml of blood in the abdominal cavity. The sigmoid colon and the mesentery were twisted at an adhesion site of a sigmoid colon to an ileum, and the condition was determined to be a sigmoid volvulus. The volvulus was observed to be loosened. The inferior mesenteric artery was incorporated into the twisted part of the mesentery, but remained patent, and its peripheral branch near the hematoma ruptured without histological abnormality. Conclusions Since ischemic-reperfusion injury occurs with a temporarily occluded artery, the acute re-loading of blood flow may injure the distal vessels after spontaneous reduction of compression by loosening of the volvulus. PMID:22129905

Point-of-care ultrasound in aerospace medicine: known and potential applications.

PubMed

Wagner, Michael S; Garcia, Kathleen; Martin, David S

2014-07-01

Since its initial introduction into the bedside assessment of the trauma patient via the Focused Assessment with Sonography for Trauma (FAST) exam, the use of point-of-care ultrasound has expanded rapidly. A growing body of literature demonstrates ultrasound can be used by nonradiologists as an extension of the physical exam to accurately diagnose or exclude a variety of conditions. These conditions include, but are not limited to, hemoperitoneum, pneumothorax, pulmonary edema, long-bone fracture, deep vein thrombosis, and elevated intracranial pressure. As ultrasound machines have become more compact and portable, their use has extended outside of hospitals to places where the physical exam and diagnostic capabilities may be limited, including the aviation environment. A number of studies using focused sonography have been performed to meet the diagnostic challenges of space medicine. The following article reviews the available literature on portable ultrasound use in aerospace medicine and highlights both known and potential applications of point-of-care ultrasound for the aeromedical clinician.

Transcatheter Arterial Embolization for Spontaneous Rupture of the Omental Artery

DOE Office of Scientific and Technical Information (OSTI.GOV)

Matsumoto, Tomohiro, E-mail: t-matsu@koto.kpu-m.ac.jp; Yamagami, Takuji; Morishita, Hiroyuki

We encountered a rare case of spontaneous rupture of the omental artery. A 25-year-old man without any episode of abdominal trauma or bleeding disorders came to the emergency unit with left upper abdominal pain. Hematoma with extravasation of the greater omentum and a hemoperitoneum was confirmed on abdominal contrast-enhanced computed tomography. Bleeding from the omental artery was suspected based on these findings. Transcatheter arterial embolization was successfully performed after extravasation of the omental artery, which arises from the left gastroepiploic artery, was confirmed on arteriography. Partial ometectomy was performed 10 days after transcatheter arterial embolization, revealing that the hematoma measuredmore » 10 cm in diameter in the greater omentum. Pathological examination showed rupture of the branch of an omental artery without abnormal findings, such as an aneurysm or neoplasm. Thus, we diagnosed him with spontaneous rupture of the omental artery. The patient recovered and was discharged from the hospital 10 days after the surgery, with a favorable postoperative course.« less

Uterine artery pseudoaneurysm in the setting of deep endometriosis: an uncommon cause of hemoperitoneum in pregnancy.

PubMed

Feld, Zoe; Rowen, Tami; Callen, Andrew; Goldstein, Ruth; Poder, Liina

2018-02-01

Uterine, ovarian, and placental pathologies are among the differential considerations for a pregnant woman presenting with abdominal and pelvic pain. Imaging plays a key role in the initial work-up of these patients. Sonography is often the first line test; however, evaluation of pelvic pathology can be limited in the gravid state, especially in mid- or late-term pregnancy. We present a case of a pregnant woman who came to the emergency room at 25 weeks with acute abdominal and pelvic pain. Both ultrasound and MR imaging findings revealed intraperitoneal hemorrhage, initially of unknown origin, as well as endometriomas and deep endometriosis. Only postpartum imaging confirmed a uterine artery pseudoaneurysm (PSA) presumably due to decidual reaction in deep endometriosis. We speculate the intraperitoneal hemorrhage was subsequently due to the PSA. This case demonstrates that if hemorrhage is not recognized promptly, it can lead to hemodynamic instability, as well as premature labor and delivery.

Ectopic Molar Pregnancy: Diagnostic Efficacy of Magnetic Resonance Imaging and Review of the Literature.

PubMed

Yamada, Yasushi; Ohira, Satoshi; Yamazaki, Teruyuki; Shiozawa, Tanri

2016-01-01

Ectopic molar pregnancy is extremely rare, and preoperative diagnosis is difficult. Our literature search found only one report of molar pregnancy diagnosed preoperatively. Moreover, there is no English literature depicting magnetic resonance image (MRI) findings of ectopic molar pregnancy. We report a case of ectopic molar pregnancy preoperatively diagnosed using MRI. A literature review of 31 cases of ectopic molar pregnancy demonstrated that lesions have been found in the fallopian tube (19 cases, 61%), ovary (5 cases, 16%), cornu (3 cases, 10%), peritoneum (2 cases, 6%), uterine cervix (1 case, 3%), and cesarean scar (1 case, 3%). Abdominal pain and abnormal vaginal bleeding were reported in 70% and 61% of the patients, respectively. Twenty-one cases (67%) presented with rupture and hemoperitoneum. All patients underwent surgical resection or dilatation and curettage. Methotrexate therapy was performed in one case because residual trophoblastic tissue was suspected. A second operation was performed in one case of ovarian molar pregnancy because serum hCG levels increased again after primary focal ovarian resection. No patients developed metastatic disease or relapsed. These findings suggest the prognosis of ectopic molar pregnancy to be favorable.

Hollow organ perforation in blunt abdominal trauma: the role of diagnostic peritoneal lavage.

PubMed

Wang, Yu-Chun; Hsieh, Chi-Hsun; Fu, Chih-Yuan; Yeh, Chun-Chieh; Wu, Shih-Chi; Chen, Ray-Jade

2012-05-01

With recent advances in radiologic diagnostic procedures, the use of diagnostic peritoneal lavage (DPL) has markedly declined. In this study, we reviewed data to reevaluate the role of DPL in the diagnosis of hollow organ perforation in patients with blunt abdominal trauma. Adult patients who had sustained blunt abdominal trauma and who were hemodynamically stable after initial resuscitation underwent an abdominal computed tomographic (CT) scan. Diagnostic peritoneal lavage was performed for patients who were indicated to receive nonoperative management and where hollow organ perforation could not be ruled out. During a 60-month period, 64 patients who had received abdominal CT scanning underwent DPL. Nineteen patients were diagnosed as having a positive DPL based on cell count ratio of 1 or higher. There were 4 patients who sustained small bowel perforation. The sensitivity and specificity of the cell count ratio for a hollow organ perforation in this study were 100% and 75%, respectively. No missed hollow organ perforations were detected. For patients with blunt abdominal trauma and hemoperitoneum who plan to receive nonoperative management, DPL is still a useful tool to exclude hollow organ perforation that is undetected by CT. Copyright © 2012 Elsevier Inc. All rights reserved.

Blunt abdominal trauma in children.

PubMed

Schonfeld, Deborah; Lee, Lois K

2012-06-01

This review will examine the current evidence regarding pediatric blunt abdominal trauma and the physical exam findings, laboratory values, and radiographic imaging associated with the diagnosis of intra-abdominal injuries (IAI), as well as review the current literature on pediatric hollow viscus injuries and emergency department disposition after diagnosis. The importance of the seat belt sign on physical examination and screening laboratory data remains controversial, although screening hepatic enzymes are recommended in the evaluation of nonaccidental trauma to identify occult abdominal organ injuries. Focused Assessment with Sonography for Trauma (FAST) has modest sensitivity for hemoperitoneum and IAI in the pediatric trauma patient. Patients with concern for undiagnosed IAI, including bowel injury, may be considered for hospital admission and serial abdominal exams without an increased risk of complications, if an exploratory laparotomy is not performed emergently. Although the FAST exam is not recommended as the sole screening tool to rule out IAI in hemodynamically stable trauma patients, it may be used in conjunction with the physical exam and laboratory findings to identify children at risk for IAI. Children with a normal physical exam and normal abdominal CT may not require routine hospitalization after blunt abdominal trauma.

A case of hepatoblastoma misdiagnosed as combined hepatocellular carcinoma and cholangiocarcinoma in an adult.

PubMed

Park, Keun Woo; Seo, Chang Jin; Yun, Dae Young; Kim, Min Keun; Kim, Byung Seok; Han, Young Seok; Oh, Hoon Kyu; Lee, Chang Hyeong

2015-09-01

Hepatoblastoma usually occurs in children under the age of 2 years, with very few cases reported in adults. We experienced a case of adult hepatoblastoma in a 36-year-old female with chronic hepatitis B. She had experienced sudden onset abdominal pain. Her serum alpha-fetoprotein level was markedly elevated, and abdominal CT showed a 9-cm mass with internal hemorrhage in the right hepatic lobe with hemoperitoneum, so an emergency hepatic central bisectionectomy was performed. The initial histologic examination revealed that the mass mimicked combined hepatocellular carcinoma and cholangiocarcinoma with spindle-cell metaplasia of the cholangiocarcinoma element. Follow-up abdominal CT performed 3 months later showed a 5.5-cm metastatic mass in the left subphrenic area. Laparoscopic splenectomy with mass excision was performed, and hepatoblastoma was confirmed histologically. A histologic re-examination of previously obtained surgical specimens also confirmed the presence of hepatoblastoma. Metastatic hepatoblastoma was found at multiple sites of the abdomen during follow-up, and so chemotherapy with cisplatin, 5-fluorouracil (5-FU), and vincristine was applied, followed by carboplatin and doxorubicin. Despite surgery and postoperative chemotherapy, she died 12 months after symptom onset.

A case of hepatoblastoma misdiagnosed as combined hepatocellular carcinoma and cholangiocarcinoma in an adult

PubMed Central

Park, Keun Woo; Seo, Chang Jin; Yun, Dae Young; Kim, Min Keun; Kim, Byung Seok; Han, Young Seok; Oh, Hoon Kyu

2015-01-01

Hepatoblastoma usually occurs in children under the age of 2 years, with very few cases reported in adults. We experienced a case of adult hepatoblastoma in a 36-year-old female with chronic hepatitis B. She had experienced sudden onset abdominal pain. Her serum alpha-fetoprotein level was markedly elevated, and abdominal CT showed a 9-cm mass with internal hemorrhage in the right hepatic lobe with hemoperitoneum, so an emergency hepatic central bisectionectomy was performed. The initial histologic examination revealed that the mass mimicked combined hepatocellular carcinoma and cholangiocarcinoma with spindle-cell metaplasia of the cholangiocarcinoma element. Follow-up abdominal CT performed 3 months later showed a 5.5-cm metastatic mass in the left subphrenic area. Laparoscopic splenectomy with mass excision was performed, and hepatoblastoma was confirmed histologically. A histologic re-examination of previously obtained surgical specimens also confirmed the presence of hepatoblastoma. Metastatic hepatoblastoma was found at multiple sites of the abdomen during follow-up, and so chemotherapy with cisplatin, 5-fluorouracil (5-FU), and vincristine was applied, followed by carboplatin and doxorubicin. Despite surgery and postoperative chemotherapy, she died 12 months after symptom onset. PMID:26523273

The expediency of peritoneal lavage for blunt trauma in children.

PubMed

Drew, R; Perry, J F; Fischer, R P

1977-12-01

Two hundred and thirty children, ten years of age or younger, suspected of having blunt abdominal injuries underwent diagnostic peritoneal lavage. Peritoneal lavage was 99.1 per cent accurate in determining the presence or absence of abdominal injuries. One patient had a false-positive peritoneal lavage. Sixty-nine of the 70 patients with blunt abdominal injuries, who underwent peritoneal lavage, had a positive peritoneal lavage; one patient had a false-negative peritoneal levage. Ninety-one per cent of the positive peritoneal lavages were grossly positive for hemoperitoneum. All 11 children with extraperitoneal abdominal injuries had positive peritoneal lavages from associated intraperitoneal injeries. The mortality for children with blunt abdominal injuries was 19.4 per cent. Intra-abdominal injuries were solely responsible for 29 per cent of the deaths and were a major contributing factor in an additional 21 per cent of the deaths. The routine use of diagnostic peritoneal lavage during the initial evaluation of blunt abdominal trauma was, in large part, responsible for the rapid, definitive treatment which -he children with abdominal injuries received. Sixty-five per cent of the children underwent exploratory laparotomy within one hour of admission to the hospital.

Management of splenic and pancreatic trauma.

PubMed

Girard, E; Abba, J; Cristiano, N; Siebert, M; Barbois, S; Létoublon, C; Arvieux, C

2016-08-01

The spleen and pancreas are at risk for injury during abdominal trauma. The spleen is more commonly injured because of its fragile structure and its position immediately beneath the ribs. Injury to the more deeply placed pancreas is classically characterized by discordance between the severity of pancreatic injury and its initial clinical expression. For the patient who presents with hemorrhagic shock and ultrasound evidence of major hemoperitoneum, urgent "damage control" laparotomy is essential; if splenic injury is the cause, prompt "hemostatic" splenectomy should be performed. Direct pancreatic injury is rarely the cause of major hemorrhage unless a major neighboring vessel is injured, but if there is destruction of the pancreatic head, a two-stage pancreatoduodenectomy (PD) may be indicated. At open laparotomy when the patient's hemodynamic status can be stabilized, it may be possible to control splenic bleeding without splenectomy; it is always essential to search for injury to the pancreatic duct and/or the adjacent duodenum. Pancreatic contusion without ductal rupture is usually treated by drain placement adjacent to the injury; ductal injuries of the pancreatic body or tail are treated by resection (distal pancreatectomy with or without splenectomy), with generally benign consequences. For injuries of the pancreatic head with pancreatic duct disruption, wide drainage is usually performed because emergency PD is a complex gesture prone to poor results. Postoperatively, the placement of a ductal stent by endoscopic retrograde catheterization may be decided, while management of an isolated pancreatic fistula is often straightforward. Non-operative management is the rule for the trauma victim who is hemodynamically stable. In addition to the clinical examination and conventional laboratory tests, investigations should include an abdominothoracic CT scan with contrast injection, allowing identification of all traumatized organs and assessment of the severity of injury. In this context, non-operative management (NOM) has gradually become the standard as long as the patient remains hemodynamically stable and there is no suspicion of injury to hollow viscera, with the patient being carefully monitored on a surgical service. The development of arteriography with splenic artery embolization has increased the rate of splenic salvage; this can be performed electively based on specific indications (blush on CT, pseudoaneurysm, arteriovenous fistula), and may also be considered for severe splenic injury, abundant hemoperitoneum, or severe polytrauma. For pancreatic injury, in addition to CT scan, magnetic resonance pancreatography (MRCP) or even endoscopic retrograde cholangiopancreatography (ERCP) may be necessary to identify a ductal rupture. If the pancreatic duct is intact, laboratory and CT imaging surveillance is performed just as for splenic injury. In case of pancreatic ductal injury, ERCP stenting can be considered. However, if this is unsuccessful, the therapeutic decision can be difficult: while NOM can still be successful, complications may arise that are difficult to treat while distal pancreatectomy, although initially more agressive may avoid these complications if performed early. Copyright © 2016 Elsevier Masson SAS. All rights reserved.

Literature Review of the Role of Ultrasound, Computed Tomography, and Transcatheter Arterial Embolization for the Treatment of Traumatic Splenic Injuries

DOE Office of Scientific and Technical Information (OSTI.GOV)

Vlies, Cornelis H. van der, E-mail: c.h.vandervlies@amc.n; Delden, Otto M. van, E-mail: o.m.vandelden@amc.n; Punt, Bastiaan J., E-mail: b.j.punt@asz.n

IntroductionThe spleen is the second most frequently injured organ following blunt abdominal trauma. Trends in management have changed over the years. Traditionally, laparotomy and splenectomy was the standard management. Presently, nonoperative management (NOM) of splenic injury is the most common management strategy in hemodynamically stable patients. Splenic injuries can be managed via simple observation (OBS) or with angiography and embolization (AE). Angio-embolization has shown to be a valuable alternative to observational management and has increased the success rate of nonoperative management in many series.DiagnosticsImproved imaging techniques and advances in interventional radiology have led to a better selection of patients whomore » are amenable to nonoperative management. Despite this, there is still a lot of debate about which patients are prone to NOM.Angiography and EmbolizationThe optimal patient selection is still a matter of debate and the role of CT and angio-embolization has not yet fully evolved. We discuss the role of sonography and CT features, such as contrast extravasation, pseudoaneurysms, arteriovenous fistulas, or hemoperitoneum, to determine the optimal patient selection for angiography and embolization. We also review the efficiency, technical considerations (proximal or selective embolization), logistics, and complication rates of AE for blunt traumatic splenic injuries.« less

Literature Review of the Role of Ultrasound, Computed Tomography, and Transcatheter Arterial Embolization for the Treatment of Traumatic Splenic Injuries

PubMed Central

van Delden, Otto M.; Punt, Bastiaan J.; Ponsen, Kees J.; Reekers, Jim A.; Goslings, J. Carel

2010-01-01

Introduction The spleen is the second most frequently injured organ following blunt abdominal trauma. Trends in management have changed over the years. Traditionally, laparotomy and splenectomy was the standard management. Presently, nonoperative management (NOM) of splenic injury is the most common management strategy in hemodynamically stable patients. Splenic injuries can be managed via simple observation (OBS) or with angiography and embolization (AE). Angio-embolization has shown to be a valuable alternative to observational management and has increased the success rate of nonoperative management in many series. Diagnostics Improved imaging techniques and advances in interventional radiology have led to a better selection of patients who are amenable to nonoperative management. Despite this, there is still a lot of debate about which patients are prone to NOM. Angiography and Embolization The optimal patient selection is still a matter of debate and the role of CT and angio-embolization has not yet fully evolved. We discuss the role of sonography and CT features, such as contrast extravasation, pseudoaneurysms, arteriovenous fistulas, or hemoperitoneum, to determine the optimal patient selection for angiography and embolization. We also review the efficiency, technical considerations (proximal or selective embolization), logistics, and complication rates of AE for blunt traumatic splenic injuries. PMID:20668852

Peliosis hepatis: Personal experience and literature review

PubMed Central

Crocetti, Daniele; Palmieri, Andrea; Pedullà, Giuseppe; Pasta, Vittorio; D’Orazi, Valerio; Grazi, Gian Luca

2015-01-01

Peliosis hepatis (PH) is a disease characterized by multiple and small, blood-filled cysts within the parenchymatous organs. PH is a very rare disease, more common in adults, and when it affects the liver, it comes to the surgeon’s attention only in an extremely urgent situation after the lesion’s rupture with the resulting hemoperitoneum. This report describes the case of a 29-year-old woman affected by recurring abdominal pain. Computed tomography scans showed a hepatic lesion formed by multiple hypodense areas, which showed an early acquisition of the contrast during the arterial phase. Furthermore, it remained isodense with the remaining parenchyma during the late venous phase. We decided on performing a liver resection of segment VII while avoiding a biopsy for safety reasons. The histopathologic examination confirmed the diagnosis of focal PH. PH should always be considered in the differential diagnosis of hepatic lesions. Clinicians should discuss the possible causes and issues related to the differential diagnosis in addition to the appropriate therapeutic approach. The fortuitous finding of a lesion, potentially compatible with PH, requires elective surgery with diagnostic and therapeutic intents. The main aim is to prevent the risk of a sudden bleeding that, in absence of properly equipped structures, may have a fatal outcome. PMID:26675327

Spontaneous rupture of a hepatic epithelioid angiomyolipoma: damage control surgery. A case report.

PubMed

Occhionorelli, S; Dellachiesa, L; Stano, R; Cappellari, L; Tartarini, D; Severi, S; Palini, G M; Pansini, G C; Vasquez, G

2013-01-01

Angiomyolipoma (AML) is a rare mesenchymal tumor composed by blood vessels, adipose tissue and smooth muscle cells in variable proportions. Although it is most often diagnosed in the kidney, this tumor may originate from any part of the liver. It is often misdiagnosed as hepatocellular carcinoma (HCC) or other benign liver tumor. We describe a case of spontaneous rupture of hepatic angiomyolipoma in a young woman, with evidence of internal hemorrhage and hemoperitoneum. Liver tumor rupture is a rare but real surgical emergency. In our case it has been managed according to the trauma principles of the damage control surgery. At the time of the observation, the patient presented an instable condition, so the decision-making was oriented toward a less invasive first step of liver packing instead of a more aggressive intervention such as one shot hepatic resection. Damage control surgery with deep parenchymal sutures of the liver and pro-coagulant tissue adhesives packing abbreviates surgical time before the development of critical and irreversible physiological endpoints and permits a more confident second time surgery. This surgical management concept helps to reduce the mortality rate and the incidence of complications not only in traumatic liver damages, it works very well in spontaneous liver ruptures as well.

Obstetrical complications of endometriosis, particularly deep endometriosis.

PubMed

Leone Roberti Maggiore, Umberto; Inversetti, Annalisa; Schimberni, Matteo; Viganò, Paola; Giorgione, Veronica; Candiani, Massimo

2017-12-01

Over the past few years, a new topic in the field of endometriosis has emerged: the potential impact of the disease on pregnancy outcomes. This review aims to summarize in detail the available evidence on the relationship between endometriosis, particularly deep endometriosis (DE), and obstetrical outcomes. Acute complications of DE, such as spontaneous hemoperitoneum, bowel perforation, and uterine rupture, may occur during pregnancy. Although these events represent life-threatening conditions, they are rare and unpredictable. Therefore, the current literature does not support any kind of prophylactic surgery before pregnancy to prevent such complications. Results on the impact of DE on obstetrical outcomes are debatable and characterized by several limitations, including small sample size, lack of adjustment for confounders, lack of adequate control subjects, and other methodologic flaws. For these reasons, it is not possible to draw conclusions on this topic. The strongest evidence shows that DE is associated with higher rates of placenta previa; for other obstetrical outcomes, such as miscarriage, intrauterine growth restriction, preterm birth and hypertensive disorders, results are controversial. Although it is unlikely that surgery of DE may modify the impact of the disease on the course of pregnancy, no study has yet investigated this issue. Copyright © 2017 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.

Non-operative management of isolated liver trauma.

PubMed

Li, Min; Yu, Wen-Kui; Wang, Xin-Bo; Ji, Wu; Li, Jie-Shou; Li, Ning

2014-10-01

Liver trauma is the most common abdominal emergency with high morbidity and mortality. Now, non-operative management (NOM) is a selective method for liver trauma. The aim of this study was to determine the success rate, mortality and morbidity of NOM for isolated liver trauma. Medical records of 81 patients with isolated liver trauma in our unit were analyzed retrospectively. The success rate, mortality and morbidity of NOM were evaluated. In this series, 9 patients with grade IV-V liver injuries underwent emergent operation due to hemodynamic instability; 72 patients, 6 with grade V, 18 grade IV, 29 grade III, 15 grade II and 4 grade I, with hemodynamic stability received NOM. The overall success rate of NOM was 97.2% (70/72). The success rates of NOM in the patients with grade I-III, IV and V liver trauma were 100%, 94.4% and 83.3%. The complication rates were 10.0% and 45.5% in the patients who underwent NOM and surgical treatment, respectively. No patient with grade I-II liver trauma had complications. All patients who underwent NOM survived. NOM is the first option for the treatment of liver trauma if the patient is hemodynamically stable. The grade of liver injury and the volume of hemoperitoneum are not suitable criteria for selecting NOM. Hepatic angioembolization associated with the correction of hypothermia, coagulopathy and acidosis is important in the conservative treatment for liver trauma.

Nonoperative management of splenic injury in combat: 2002-2012.

PubMed

Mitchell, Thomas A; Wallum, Timothy E; Becker, Tyson E; Aden, James K; Bailey, Jeffrey A; Blackbourne, Lorne H; White, Christopher E

2015-03-01

Selective nonoperative management of combat-related blunt splenic injury (BSI) is controversial. We evaluated the impact of the November 2008 blunt abdominal trauma clinical practice guideline that permitted selective nonoperative management of some patients with radiological suggestion of hemoperitoneum on implementation of nonoperative management (NOM) of splenic injury in austere environments. Retrospective evaluation of patients with splenic injuries from November 2002 through January 2012 in Iraq and Afghanistan was performed. International Classification of Diseases, 9th Revision, Clinical Modification procedure codes identified patients as laparotomy with splenectomy, or NOM. Delayed operative management had no operative intervention at earlier North American Treaty Organization (NATO) medical treatment facilities (MTFs), and had a definitive intervention at a latter NATO MTFs. Intra-abdominal complications and overall mortality were juxtaposed. A total of 433 patients had splenic injuries from 2002 to 2012. Initial NOM of BSI from 2002 to 2008 compared to 2009-2012 was 44.1% and 47.2%, respectively (p=0.75). Delayed operative management and NOM completion had intra-abdominal complication and mortality rates of 38.1% and 9.1% (p<0.01), and 6.3% and 8.1% (p=0.77). Despite high-energy explosive injuries, NATO Role II MTFs radiological constraints and limited medical resources, hemodynamically normal patients with BSI and low abdominal abbreviated injury scores underwent NOM in austere environments. Reprint & Copyright © 2015 Association of Military Surgeons of the U.S.

Extrahepatic duct injury in blunt trauma: two case reports and a literature review.

PubMed

Zago, Thiago Messias; Pereira, Bruno Monteiro Tavares; Calderan, Thiago Rodrigues Araujo; Hirano, Elcio Shiyoiti; Fraga, Gustavo Pereira

2014-08-01

Traumatic injuries of the extrahepatic biliary tract are rare. Associated injuries are usually responsible for immediate indication for surgical treatment, the time when an injury to the extrahepatic biliary ducts may be diagnosed. However, missed injuries are often common. The primary aim of this paper is to describe the clinical features, diagnosis, treatment, and outcome of two patients with left hepatic duct injury after blunt abdominal trauma. As a secondary objective, a literature review is presented. The two cases presented in this study are as follows: (1) A young male, involved in a motor vehicle crash, was admitted with blunt hepatic trauma in a general hospital. Endoscopic retrograde cholangiography was conducted 3 weeks later and revealed a large leakage at the left hepatic duct. Exploratory laparotomy was performed 26 days after the initial traumatic event and identified a complete section of the left hepatic duct, treated with anastomosis. (2) A male fell from a height. On exploratory laparotomy, a 30 % partial injury of the left hepatic duct was found in addition to hemoperitoneum, liver injury, gallbladder detachment together with cystic duct rupture, retroperitoneal hematoma to the right, and cecum hematoma. A high level of suspicion is necessary to identify injuries to the hepatic ducts. Early diagnosis that occurs during laparotomy due to associated injuries is important to reduce complications.

Spontaneous rupture of hepatic hemangiomas: A review of the literature.

PubMed

Ribeiro, Marcelo Af; Papaiordanou, Francine; Gonçalves, Juliana M; Chaib, Eleazar

2010-12-27

Hepatic hemangiomas are congenital vascular malformations, considered the most common benign mesenchymal hepatic tumors, composed of masses of blood vessels that are atypical or irregular in arrangement and size. Hepatic hemangiomas can be divided into two major groups: capillary hemangiomas and cavernous hemangiomas These tumors most frequently affect females (80%) and adults in their fourth and fifth decades of life. Most cases are asymptomatic although a few patients may present with a wide variety of clinical symptoms, with spontaneous or traumatic rupture being the most severe complication. In cases of spontaneous rupture, clinical manifestations consist of sudden abdominal pain, and anemia secondary to a haemoperitoneum. Disseminated intravascular coagulopathy can also occur. Haemodynamic instability and signs of hypovolemic shock appear in about one third of cases. As the size of the hemangioma increases, so does the chance of rupture. Imaging studies used in the diagnosis of hepatic hemangiomas include ultrasonography, dynamic contrast-enchanced computed tomography scanning, magnetic resonance imaging, hepatic arteriography, digital subtraction angiography, and nuclear medicine studies. In most cases hepatic hemangiomas are asymptomatic and should be followed up by means of periodic radiological examination. Surgery should be restricted to specific situations. Absolute indications for surgery are spontaneous or traumatic rupture with hemoperitoneum, intratumoral bleeding and consumptive coagulopathy (Kassabach-Merrit syndrome). In a patient presenting with acute abdominal pain due to unknown abdominal disease, spontaneous rupture of a hepatic tumor such as a hemangioma should be considered as a rare differential diagnosis.

False negative pericardial Focused Assessment with Sonography for Trauma examination following cardiac rupture from blunt thoracic trauma: a case report.

PubMed

Baker, Laura; Almadani, Ammar; Ball, Chad G

2015-07-15

The Focused Assessment with Sonography for Trauma examination is an invaluable tool in the initial assessment of any injured patient. Although highly sensitive and accurate for identifying hemoperitoneum, occasional false negative results do occur in select scenarios. We present a previously unreported case of survival following blunt cardiac rupture with associated negative pericardial window due to a concurrent pericardial wall laceration. A healthy 46-year-old white woman presented to our level 1 trauma center with hemodynamic instability following a motor vehicle collision. Although her abdominal Focused Assessment with Sonography for Trauma windows were positive for fluid, her pericardial window was negative. After immediate transfer to the operating room in the setting of persistent instability, a subsequent thoracotomy identified a blunt cardiac rupture that was draining into the ipsilateral pleural space via an adjacent tear in the pericardium. The cardiac injury was controlled with digital pressure, resuscitation completed, and then repaired using standard cardiorrhaphy techniques. Following repair of her injuries (left ventricle, left atrial appendage, and liver), her postoperative course was uneventful. Evaluation of the pericardial space using Focused Assessment with Sonography for Trauma is an important component in the initial assessment of the severely injured patient. Even in cases of blunt mechanisms however, clinicians must be wary of occasional false negative pericardial ultrasound evaluations secondary to a concomitant pericardial laceration and subsequent decompression of hemorrhage from the cardiac rupture into the ipsilateral pleural space.

Transjugular liver biopsy with use of the shark jaw needle: diagnostic yield, complications, and cost-effectiveness.

PubMed

Psooy, B J; Clark, T W; Beecroft, J R; Malatjalian, D

2001-01-01

Obtaining transjugular liver biopsy specimens with use of single-use needle systems is expensive, whereas biopsy specimens obtained with use of reusable needle systems are frequently associated with inadequate core specimens. The authors report their experience with the reusable Cook Shark Jaw biopsy needle, including diagnostic yield, complications, and cost-effectiveness. A retrospective audit was performed of a cohort of 134 patients who underwent 136 transjugular liver biopsies with use of a reusable 16-gauge Shark Jaw needle during a 30-month period. Specimen adequacy and complication rates were assessed and direct costs of expendable components calculated. Cost-effectiveness was expressed as cost-per-successful biopsy. Biopsies were technically successful in 126 of 136 (93%) patients, with diagnostic histologic core specimens obtained in 124 of 126 (98%) patients, for an overall success rate of 91%. Complications included capsular penetration in six (4.4%) patients, cardiac arrhythmia in two (1.5%) patients, and puncture site hematoma or bleeding in 10 (7.4%) patients. Three tract embolizations were performed for capsular penetration. No instances of subcapsular hematoma, hemoperitoneum, or sepsis occurred, and no deaths were attributed to the procedure. The cost of expendable components totaled $103 per biopsy, corresponding to a cost-effectiveness of $113/successful biopsy. Transjugular liver biopsy specimens obtained with use of the Shark Jaw needle have a diagnostic yield comparable to those obtained with use of single-use biopsy systems, at a substantially lower cost with no increase in serious complications.

Endovascular treatment of a blunt aortic injury in Iraq: extension of innovative endovascular capabilities to the modern battlefield.

PubMed

Propper, Brandon W; Alley, Joshua B; Gifford, Shaun M; Burkhardt, Gabriel E; Rasmussen, Todd E

2009-01-01

The management of blunt descending thoracic aortic injury remains controversial. Despite emerging evidence touting the advantage of endovascular repair in civilian trauma, there have been no reports on the application of this management strategy in the austere environment of war. We provide a case report from the 332nd EMDG/Air Force Theater Hospital, Balad Air Base, Iraq. An Iraqi policeman presented with traumatic aortic disruption following blunt trauma. The patient arrived with hemoperitoneum, a Le Fort III facial fracture, a left humerus fracture, and a thoracic aortic disruption. Following facial packing, fracture stabilization, and damage control laparotomy, aortography was performed, confirming aortic disruption beyond the left subclavian artery. The injury was treated with three aortic cuffs (Gore Excluder AAA Aortic Extender Endoprostheses) placed in sequence from the origin of the left subclavian across the disruption. A type III endoleak was successfully managed with placement of one additional aortic cuff. The patient was discharged after 1 month following the successful treatment of his other injuries. Computed tomography angiography at 10 and 30 days following the procedure revealed no endoleak and a resolved periaortic hematoma. This report details the first endovascular treatment of blunt aortic injury in wartime and represents a sustained commitment to advance innovative endovascular capability closer to the time of injury. Although controversial, this less invasive approach is appealing in patients with high injury severity scores, making its availability in wartime especially germane.

Hemorrhage and blood loss-induced anemia associated with an acquired coagulation factor VIII inhibitor in a Thoroughbred mare.

PubMed

Winfield, Laramie S; Brooks, Marjory B

2014-03-15

A 23-year-old Thoroughbred mare was evaluated because of a coagulopathy causing hemoperitoneum, hematomas, and signs of blood loss-induced anemia. The mare had tachycardia, pallor, hypoperfusion, and a large mass in the right flank. The mass was further characterized ultrasonographically as an extensive hematoma in the body wall with associated hemoabdomen. Coagulation testing revealed persistent, specific prolongation of the activated partial thromboplastin time (> 100 seconds; reference interval, 24 to 44 seconds) attributable to severe factor VIII deficiency (12%; reference interval, 50% to 200%). On the basis of the horse's age, lack of previous signs of a bleeding diathesis, and subsequent quantification of plasma factor VIII inhibitory activity (Bethesda assay titer, 2.7 Bethesda units/mL), acquired hemophilia A was diagnosed. The medical history did not reveal risk factors or underlying diseases; thus, the development of inhibitory antibodies against factor VIII was considered to be idiopathic. The mare was treated with 2 transfusions of fresh whole blood and fresh-frozen plasma. Immunosuppressive treatment consisting of dexamethasone and azathioprine was initiated. Factor VIII deficiency and signs of coagulopathy resolved, and the inhibitory antibody titer decreased. The mare remained healthy with no relapse for at least 1 year after treatment. Horses may develop inhibitory antibodies against factor VIII that cause acquired hemophilia A. A treatment strategy combining transfusions of whole blood and fresh-frozen plasma and administration of immunosuppressive agents was effective and induced sustained remission for at least 1 year in the mare described here.

Development and results of a novel pancreas transplant program in Spain: the surgeon's point of view.

PubMed

Muñoz-Bellvis, Luis; Esteban, María Del Carmen; Iglesias, Manuel; González, Luis; González-Muñoz, Juan Ignacio; Muñoz-González, Cristina; E Quiñones, José; Tabernero, Guadalupe; Iglesias, Rosa Ana; Sayagués, José María; Fraile, Pilar

2018-04-01

Simultaneous kidney-pancreas transplantation for patients with type 1 diabetes and end-stage chronic renal disease is widely performed. However, the rate of surgical morbidity from pancreatic complications remains high. The aim of this study was to describe the development and results of a new program, from the point of view of the pancreatic surgeon. We analyzed 53 simultaneous kidney-pancreas transplantations performed over a period of seven years (2009-2016), with a median follow up of 39 months (range: 1-86 months). Out of the total of this series, two patients died: one patient because of cardiac arrest immediately after surgery; and another patient due to traffic accident, complicated by pneumonia. Among the 51 living patients, two grafts were lost: one due to chronic rejection four years after transplantation; and the other due to arterial thrombosis 20 days after transplantation (the only case requiring transplantectomy). In ten patients, one or more re-operations were necessary due to the following: graft pancreatitis (n=4), small intestinal obstruction (n=4), arterial thrombosis (n=1), fistula (n=1) and hemoperitoneum (n=1). Overall patient and graft survival rates after 1, 3 and 5 years were 98, 95 and 95% and 96, 93 and 89%, respectively. This study has shown that the results of a new pancreas transplant program, which relies on the previous experience of other groups, do not demonstrate a learning curve. Adequate surgeon education and training, as well as the proper use of standardized techniques, should ensure optimal results. Copyright © 2018 AEC. Publicado por Elsevier España, S.L.U. All rights reserved.

Laparoscopic ileocecal resection in acute and chronic presentations of Crohn’s disease. A single center experience

PubMed Central

COCORULLO, G.; TUTINO, R.; FALCO, N.; SALAMONE, G.; FONTANA, T.; LICARI, L.; GULOTTA, G.

2016-01-01

Introduction The terminal ileum is the most involved tract in Crohn’s disease. The obstruction in this location is the most frequent complication. Acute or chronic presentations can occur. Surgery finds a role in the management of chronic strictures and in acute clinical presentations with complications not improving with conservative therapy. Patients and methods We investigate the outcome of patients with obstruction of the ileo-cecal bowel tract laparoscopically managed. It was analyzed the average operative time (OT), the conversion rate and the occurrence of re-operation due to surgical complications. Results 21 patients underwent an ileocecal resection for complicated Crohn’s disease between January 2013 and December 2014. The admissions were performed in emergency in 42% of patients. The pre-intervention hospital stay was 5.8 (Sd 6.23). The mean operative time was 154 min (Sd 41). 28% of the procedures were converted to open surgery. The average hospital stay was 10 days (Sd 5) in uncomplicated patients. The morbidity rate was 28%. In 19% of cases a re-intervention was needed due to anastomotic leakage (3pts) and one hemoperitoneum for bleeding from the suture line. Discussion Laparoscopy seems an affordable technique in the management of obstructive pattern of Crohn’s disease. It should be the preferable approach in young patients that probably will be submitted to subsequent surgery for the same disease; in fact, the reduced adhesions formation provided by the less bowel manipulation make easy the subsequent access. Older patients had usually more post-operative morbidity and mortality mostly due to pre-existing conditions; if possible in these patients the treatment should be medical. PMID:28098059

The clinical and technical evaluation of a remote telementored telesonography system during the acute resuscitation and transfer of the injured patient.

PubMed

Dyer, Dianne; Cusden, Jane; Turner, Chris; Boyd, Jeff; Hall, Rob; Lautner, David; Hamilton, Douglas R; Shepherd, Lance; Dunham, Michael; Bigras, Andre; Bigras, Guy; McBeth, Paul; Kirkpatrick, Andrew W

2008-12-01

Ultrasound (US) has an ever increasing scope in the evaluation of trauma, but relies greatly on operator experience. NASA has refined telesongraphy (TS) protocols for traumatic injury, especially in reference to mentoring inexperienced users. We hypothesized that such TS might benefit remote terrestrial caregivers. We thus explored using real-time US and video communication between a remote (Banff) and central (Calgary) site during acute trauma resuscitations. A existing internet link, allowing bidirectional videoconferencing and unidirectional US transmission was used between the Banff and Calgary ERs. Protocols to direct or observe an extended focused assessment with sonography for trauma (EFAST) were adapted from NASA algorithms. A call rota was established. Technical feasibility was ascertained through review of completed checklists. Involved personnel were interviewed with a semistructured interview. In addition to three normal volunteers, 20 acute clinical examinations were completed. Technical challenges requiring solution included initiating US; audio and video communications; image freezing; and US transmission delays. FAST exams were completed in all cases and EFASTs in 14. The critical anatomic features of a diagnostic examination were identified in 98% of all FAST exams and a 100% of all EFASTs that were attempted. Enhancement of clinical care included confirmation of five cases of hemoperitoneum and two pneumothoraces (PTXs), as well as educational benefits. Remote personnel were appreciative of the remote direction particularly when instructions were given sequentially in simple, nontechnical language. The remote real-time guidance or observation of an EFAST using TS appears feasible. Most technical problems were quickly overcome. Further evaluation of this approach and technology is warranted in more remote settings with less experienced personnel.

Accuracy of Focused Assessment with Sonography for Trauma (FAST) in Blunt Trauma Abdomen-A Prospective Study.

PubMed

Kumar, Subodh; Bansal, Virinder Kumar; Muduly, Dillip Kumar; Sharma, Pawan; Misra, Mahesh C; Chumber, Sunil; Singh, Saraman; Bhardwaj, D N

2015-12-01

Focused assessment with sonography for trauma (FAST) is a limited ultrasound examination, primarily aimed at the identification of the presence of free intraperitoneal or pericardial fluid. In the context of blunt trauma abdomen (BTA), free fluid is usually due to hemorrhage, bowel contents, or both; contributes towards the timely diagnosis of potentially life-threatening hemorrhage; and is a decision-making tool to help determine the need for further evaluation or operative intervention. Fifty patients with blunt trauma abdomen were evaluated prospectively with FAST. The findings of FAST were compared with contrast-enhanced computed tomography (CECT), laparotomy, and autopsy. Any free fluid in the abdomen was presumed to be hemoperitoneum. Sonographic findings of intra-abdominal free fluid were confirmed by CECT, laparotomy, or autopsy wherever indicated. In comparing with CECT scan, FAST had a sensitivity, specificity, and accuracy of 77.27, 100, and 79.16 %, respectively, in the detection of free fluid. When compared with surgical findings, it had a sensitivity, specificity, and accuracy of 94.44, 50, and 90 %, respectively. The sensitivity of FAST was 75 % in determining free fluid in patients who died when compared with autopsy findings. Overall sensitivity, specificity, and accuracy of FAST were 80.43, 75 and 80 %, respectively, for the detection of free fluid in the abdomen. From this study, we can safely conclude that FAST is a rapid, reliable, and feasible investigation in patients with BTA, and it can be performed easily, safely, and quickly in the emergency room with a reasonable sensitivity, specificity, and accuracy. It helps in the initial triage of patients for assessing the need for urgent surgery.

Analysis of laparoscopy in trauma.

PubMed

Villavicencio, R T; Aucar, J A

1999-07-01

The optimum roles for laparoscopy in trauma have yet to be established. To date, reviews of laparoscopy in trauma have been primarily descriptive rather than analytic. This article analyzes the results of laparoscopy in trauma. Outcome analysis was done by reviewing 37 studies with more than 1,900 trauma patients, and laparoscopy was analyzed as a screening, diagnostic, or therapeutic tool. Laparoscopy was regarded as a screening tool if it was used to detect or exclude a positive finding (eg, hemoperitoneum, organ injury, gastrointestinal spillage, peritoneal penetration) that required operative exploration or repair. Laparoscopy was regarded as a diagnostic tool when it was used to identify all injuries, rather than as a screening tool to identify the first indication for a laparotomy. It was regarded as a diagnostic tool only in studies that mandated a laparotomy (gold standard) after laparoscopy to confirm the diagnostic accuracy of laparoscopic findings. Costs and charges for using laparoscopy in trauma were analyzed when feasible. As a screening tool, laparoscopy missed 1% of injuries and helped prevent 63% of patients from having a trauma laparotomy. When used as a diagnostic tool, laparoscopy had a 41% to 77% missed injury rate per patient. Overall, laparoscopy carried a 1% procedure-related complication rate. Cost-effectiveness has not been uniformly proved in studies comparing laparoscopy and laparotomy. Laparoscopy has been applied safely and effectively as a screening tool in stable patients with acute trauma. Because of the large number of missed injuries when used as a diagnostic tool, its value in this context is limited. Laparoscopy has been reported infrequently as a therapeutic tool in selected patients, and its use in this context requires further study.

Role of the transjugular intrahepatic portosystemic shunt in the management of severe complications of portal hypertension in idiopathic noncirrhotic portal hypertension.

PubMed

Bissonnette, Julien; Garcia-Pagán, Juan Carlos; Albillos, Agustín; Turon, Fanny; Ferreira, Carlos; Tellez, Luis; Nault, Jean-Charles; Carbonell, Nicolas; Cervoni, Jean-Paul; Abdel Rehim, Mohamed; Sibert, Annie; Bouchard, Louis; Perreault, Pierre; Trebicka, Jonel; Trottier-Tellier, Félix; Rautou, Pierre-Emmanuel; Valla, Dominique-Charles; Plessier, Aurélie

2016-07-01

Idiopathic noncirrhotic portal hypertension is a heterogeneous group of diseases characterized by portal hypertension in the absence of cirrhosis. The efficacy and safety of transjugular intrahepatic portosystemic shunt (TIPS) in this population are unknown. The charts of patients with idiopathic noncirrhotic portal hypertension undergoing TIPS in seven centers between 2000 and 2014 were retrospectively reviewed. Forty-one patients were included. Indications for TIPS were recurrent variceal bleeding (n = 25) and refractory ascites (n = 16). Patients were categorized according to the presence (n = 27) or absence (n = 14) of significant extrahepatic comorbidities. Associated conditions were hematologic, prothrombotic, neoplastic, immune, and exposure to toxins. During follow-up (mean 27 ± 29 months), variceal rebleeding occurred in 7/25 (28%), including three with early thrombosis of the stent. Post-TIPS overt hepatic encephalopathy was present in 14 patients (34%). Eleven patients died, five due the liver disease or complications of the procedure and six because of the associated comorbidities. The procedure was complicated by hemoperitoneum in four patients (10%), which was fatal in one case. Serum creatinine (P = 0.005), ascites as indication for TIPS (P = 0.04), and the presence of significant comorbidities (P = 0.01) at the time of the procedure were associated with death. Mortality was higher in patients with significant comorbidities and creatinine ≥100 μmol/L (P < 0.001). In patients with idiopathic noncirrhotic portal hypertension who have normal kidney function or do not have severe extrahepatic conditions, TIPS is an excellent option to treat severe complications of portal hypertension. (Hepatology 2016;64:224-231). © 2016 by the American Association for the Study of Liver Diseases.

Comparison of Transjugular Liver Biopsy and Percutaneous Liver Biopsy With Tract Embolization in Pediatric Patients.

PubMed

Tulin-Silver, Sheryl; Obi, Chrystal; Kothary, Nishita; Lungren, Matthew

2018-03-05

The aim of the study was to compare safety and efficacy of transjugular liver biopsy (TJLB) and percutaneous liver biopsy (PLB) with tract embolization in pediatric patients with liver disease. TJLB and PLB between December 2009 and October 2015 were retrospectively reviewed. Primary endpoints were adequate sampling and complication rate. Patient age, weight, coagulation factors, ascites, blood transfusions, adequacy of biopsy sample, number of biopsy samples, and complications were compared. There were 39 TJLB (average age 10.6 years) and 120 PLB (average age 7.1 years) (P value <0.05). Average weight was 40.2 kg for TJLB and 26.8 kg for PLB (P value <0.05). Average platelets were 155 for TJLB and 252 for PLB (P value <0.05). Average INR was 1.7 for TJLB and 1.3 for PLB (P value <0.05). Mean postbiopsy hematocrit decrease was 0.8 and 0.9, for TJLB and PLB, respectively. Mean postbiopsy hemoglobin decrease was 0.3 in both groups. Number of core biopsy samples was 4.5 and 4.3, for TJLB and PLB, respectively. There was 1 biopsy yielding insufficient sample in each group. TJLB had 1 (2.6%) complication of supraventricular tachycardia. PLB had 4 (3.3%) complications, with 1 hemoperitoneum, 1 hypotension, 1 patient with decreased hemoglobin, and 1 patient with bilious drainage from the biopsy site. TJLB and PLB with gelatin sponge pledget tract embolization are both safe and effective for the diagnosis of hepatic disease in pediatric patients. To avoid radiation, PLB may be considered as first-line approach in the pediatric population, even in the setting of coagulopathy.

The role of pancreatic leakage on rising of postoperative complications following pancreatic surgery.

PubMed

Benzoni, Enrico; Saccomano, Enrico; Zompicchiatti, Aron; Lorenzin, Dario; Baccarani, Umberto; Adani, Gian Luigi; Uzzau, Alessandro; Noce, Luigi; Cedolini, Carla; Bresadola, Fabrizio; De Anna, Dino; Intini, Sergio

2008-10-01

The variations in methods of pancreatic stump management and the volume of literature available on both main pancreatic duct and pancreaticoenetric anastomosis leak indicates the concern associated with the leak and the continuing efforts to prevent it. Herein we analyzed the role of pancreatic leakage followed by pancreatic surgery on the incidence of postoperative morbidity. From 1989 to 2005, we performed 76 pancreaticoduodenectomy (PD) and 26 distal pancreatectomy (DP), assumed as control case). During DP the parenchymal transection was performed with a linear stapler. The surgical reconstruction after PD was as follows: 11 manual nonabsorbable stitch closure of the main duct, 24 closure of the main duct with linear stapler, 17 temporary occlusion of the main duct with neoprene glue, and 24 duct-to-mucosa anastomosis. In the PD group, morbidity rate was 60%, caused by pancreatic leakage, with an incidence of 48%, hemorrhagic complication, occurred in 10% of patients following surgical procedure and infectious complication, with an incidence of 15%. After distal pancreatectomy we recorded 80, 7% no complications, 3, 9% leakage, 15, 4% hemoperitoneum. By multivariate analysis bleeding complications, biliary anastomosis leakage, and infectious complications were consequences of pancreatic leakage (P = 0.025, P = 0.025, and P = 0.025, respectively). A significant statistical difference was recorded analyzing re-operation rates between closure of the main duct with linear stapler versus temporary occlusion of the main duct with neoprene glue (t = 0.049) and closure of the main duct with linear stapler versus duct-to-mucosa anastomosis (t = 0.003). On the ground of our results of bleeding complication, biliary anastomosis leakage and infectious complication were consequences of pancreatic leakage: failure of a surgical anastomosis has serious consequences, particularly in case of anastomosis of the pancreas to the small bowel, because of the digestive capacities of activated pancreatic secretions.

Impact of Three-Dimensional Laparoscopy in a Bariatric Surgery Program: Influence in the Learning Curve.

PubMed

Padin, Esther Mariño; Santos, Raquel Sánchez; Fernández, Sonia González; Jimenez, Antonia Brox; Fernández, Sergio Estevez; Dacosta, Ester Carrera; Duran, Agata Rial; Artime Rial, Maria; Dominguez Sanchez, Ivan

2017-10-01

3D laparoscopy allows the surgeon to regain the sense of depth and improve accuracy. The aim of the study was to assess the impact of 3D in bariatric surgery. A retrospective cohort study was conducted. All our patients who underwent bariatric surgery (sleeve gastrectomy (SG) or gastric bypass (GB)) between 2013 and 2016 were included. We compared 3D laparoscopy cohort and 2D laparoscopy cohort. Variables are as follows: age, sex, DM, hypertension, surgeon experience, and type of intervention. Comparisons of operative time, hospital stay, conversion, complications, reoperation, and exitus are completed. Three hundred twelve consecutive patients were included. 56.9% of patients underwent GB and 43.1% SG. Global complications were 3.2% (fistula 2.5%, hemoperitoneum 0.3%, others 0.4%). One hundred four procedures were performed in the 3D cohort and 208 in the 2D cohort. The 2D cohort and 3D cohort were similar regarding the following: percentage of GB vs SG, age, gender, learning curve, diabetes mellitus 2, hypertension, and sleep apnea. The operating time and hospital stay were significantly reduced in the 3D cohort (144.07 ± 58.07 vs 172.11 ± 76.11 min and 5.12 ± 9.6 vs 7.7 ± 13.2 days. It was the same when we stratified the sample by type of surgery or experience of the surgeon. Complications were reduced in the 3D cohort in the surgeries performed by novice surgeons (10.2 vs 1.8%, p = 0.034). The use of 3D laparoscopy in bariatric surgery in our center has helped reducing the operating time and hospital stay, and improving the safety of the surgery, either in GB or SG, being equally favorable in novice or more experienced surgeons.

The focused abdominal sonography for trauma examination can reliably identify patients with significant intra-abdominal hemorrhage in life-threatening pelvic fractures.

PubMed

Christian, Nicole Townsend; Burlew, Clay Cothren; Moore, Ernest E; Geddes, Andrea E; Wagenaar, Amy E; Fox, Charles J; Pieracci, Fredric M

2018-06-01

The focused abdominal sonography for trauma (FAST) examination has been reported to be unreliable in pelvic fracture patients. Additionally, given the advent of new therapeutic interventions, such as resuscitative endovascular balloon occlusion of the aorta (REBOA), rapid identification of intra-abdominal hemorrhage compared with Zone III hemorrhage may guide different therapeutic strategies. We hypothesized that FAST is reliable for detecting clinically significant intra-abdominal hemorrhage in the face of complex pelvic fractures. Our pelvic fracture database of all hemodynamically unstable patients requiring intervention from January 1, 2005, to July 1, 2015, was reviewed. The FAST examination was compared with operative and computed tomography (CT) scan findings. Confirmatory evaluation for FAST(-) patients was considered positive if therapeutic intervention was required. During the study period, 81 patients in refractory shock with FAST imaging in our emergency department (ED) underwent pelvic packing. Mean age was 45 ± 2 years and Injury Severity Score was 50 ± 1.5. The FAST examination was negative in 53 patients; 52 patients did not require operative intervention for abdominal bleeding while one patient required splenectomy. The FAST examination was positive in 28 patients; 26 had findings confirmed by CT or laparotomy while two patients did not have intra-abdominal hemorrhage on further evaluation. The sensitivity and specificity for FAST in this population was 96% and 96%, respectively, positive predictive value was 93%, and negative predictive value was 98%. The false-negative and -positive rates for FAST were 2% and 7%. Focused abdominal sonography for trauma examination reliably identifies clinically significant hemoperitoneum in life-threatening, pelvic fracture related hemorrhage. The incidence of a false-negative FAST in this unstable pelvic fracture population was 2%. FAST results may be used when determining the role of REBOA in these multisystem trauma patients and requires further study. REBOA placement should be considered in hemodynamically unstable pelvic fracture patients who are FAST(-), while laparotomy should be used in FAST(+) patients. Therapeutic, level IV.

Delayed Enhancement of Ascites After IV Contrast Material Administration at CT: Time Course and Clinical Correlation

PubMed Central

Benedetti, Nancy; Aslam, Rizwan; Wang, Zhen J.; Joe, Bonnie N.; Fu, Yanjun; Yee, Judy; Yeh, Benjamin M.

2010-01-01

OBJECTIVE The objective of our study was to determine the prevalence and clinical predictors of delayed contrast enhancement of ascites. MATERIALS AND METHODS In this retrospective study, 132 consecutive patients with ascites who underwent repeated abdominopelvic CT examinations performed within 7 days of each other were identified. These patients included 112 patients who received and 20 who did not receive IV contrast material at the initial CT examination. For each examination, we recorded the CT attenuation of the ascites. For the follow-up scan, the presence of delayed enhancement of ascites was defined as an increase in CT attenuation > 10 HU over baseline. The Fisher’s exact test, unpaired Student’s t test, and logistic regression were used to determine predictors of delayed enhancement of ascites. RESULTS A threshold increase in the attenuation of ascites by > 10 HU or more between the initial and follow-up CT examinations occurred only when IV contrast material was given with the initial examination. The increased attenuation was due to delayed contrast enhancement of ascites and occurred in 15 of the 112 patients (13%). Of the 16 patients scanned less than 1 day apart, 10 (63%) showed delayed enhancement of ascites. Delayed enhancement was not observed 3 or more days after IV contrast material administration. For each 1 mg/dL increase in serum creatinine level, the likelihood of delayed enhancement of ascites increased (odds ratio, 2.02; 95% CI, 1.11–3.69). Multivariate logistic regression showed that a short time interval between examinations (p < 0.001), increased serum creatinine level (p < 0.001), and presence of loculated ascites (p = < 0.01) were independent predictors of the magnitude of delayed enhancement of ascites. CONCLUSION Delayed contrast enhancement of ascites occurs commonly after recent prior IV contrast material administration and should not be mistaken for hemoperitoneum or proteinaceous fluid such as pus. PMID:19696286

Capnocytophaga canimorsus infection presenting with complete splenic infarction and thrombotic thrombocytopenic purpura: a case report.

PubMed

Brichacek, Michal; Blake, Peter; Kao, Raymond

2012-12-26

Animal bites are typically harmless, but in rare cases infections introduced by such bites can be fatal. Capnocytophaga canimorsus, found in the normal oral flora of dogs, has the potential to cause conditions ranging from minor cellulitis to fatal sepsis. The tendency of C. canimorsus infections to present with varied symptoms, the organism's fastidious nature, and difficulty of culturing make this a challenging diagnosis. Rarely, bacterial cytotoxins such as those produced by C. canimorsus may act as causative agents of TTP, further complicating the diagnosis. Early recognition is crucial for survival, and the variability of presentation must be appreciated. We present the first known case of C. canimorsus infection resulting in TTP that initially presented as splenic infarction. 72-year-old Caucasian male presented with a four-day history of abdominal pain, nausea, vomiting, diarrhea, and intermittent confusion. On presentation, vital signs were stable and the patient was afebrile. Physical examination was unremarkable apart from petechiae on the inner left thigh, and extreme diffuse abdominal pain to palpation and percussion along with positive rebound tenderness. Initial investigations revealed leukocytosis with left shift and thrombocytopenia, but normal liver enzymes, cardiac enzymes, lipase, INR and PTT. Abdominal CT demonstrated a non-enhancing spleen and hemoperitoneum, suggesting complete splenic infarction. Although the patient remained afebrile, he continued deteriorating over the next two days with worsening thrombocytopenia. After becoming febrile, he developed microangiopathic hemolytic anemia and hemodynamic instability, and soon after was intubated due to hypoxic respiratory failure and decreased consciousness. Plasma exchange was initiated but subsequently stopped when positive blood cultures grew a gram-negative organism. The patient progressively improved following therapy with piperacillin-tazobactam, which was switched to imipenem, then meropenem when Capnocytophaga was identified. There is a common misconception amongst practitioners that the presence of systemic infection excludes the possibility of TTP and vice versa. This case emphasizes that TTP may occur secondary to a systemic infection, thereby allowing the two processes to coexist. It is important to maintain a wide differential when considering the diagnosis of either TTP or C. canimorsus infection since delays in treatment may have fatal consequences.

Clinical management of a unique case of PNET of the uterus during pregnancy, and review of the literature.

PubMed

De Nola, Rosalba; Di Naro, Edoardo; Schonauer, Luca Maria; Lucarelli, Giuseppe; Battaglia, Michele; Fiore, Maria Grazia; Mastrolia, Salvatore Andrea; Loverro, Giuseppe

2018-01-01

PNETs (primitive neuroectodermal tumors) are a family of highly malignant neoplasms characterized by small round cells of neuroepithelial origin. They usually involve bone and soft tissues, and have a higher incidence in childhood. In this case report, we describe the obstetric and oncological outcome of a huge mass diagnosed as a leiomyoma in a 39-year-old pregnant woman who complained of low back pain, dysuria, and urinary frequency at 22 weeks of gestation. During the 25th week of pregnancy, the patient was referred to our hospital at night with severe anemia and suspected hemoperitoneum. She underwent an emergency caesarean section, delivering a female fetus weighing 400 g, with an Apgar score of 7 at 1 minute and 9 at 5 minutes. During surgery, we found a huge uterine sarcoma-like metastatic tumor, invading the pelvic peritoneum and parametria bilaterally; the adnexae seemed disease-free. We performed a type B radical hysterectomy, bilateral salpingo-oophorectomy, pelvic peritonectomy, omentectomy, appendectomy, and excision of a bulky lymph node. Seven days after delivery, staging computed tomography (CT) scan demonstrated a large lombo-aortic lymph node compressing the left renal vein and we completed debulking with a second surgery, including diaphragmatic peritonectomy and excision of a huge lymph node by lombo-aortic lymphadenectomy, requiring partial reconstruction of an infiltrated renal vein. Ten days after the second surgery, echo-color Doppler showed a regular microcirculation in the left kidney. The patient was discharged after 10 days, and the baby after 1 month, both in good health.Histological examination revealed a uterine body cPNET (central primitive neuroectodermal tumor) orienting the clinical management toward chemotherapy with cisplatin and etoposide. PNETs are aggressive neoplasms, usually diagnosed at an advanced stage. Due to their low incidence, universally accepted guidelines are still unavailable. Radical surgery leaving no macroscopic residual disease is mandatory in advanced stages. A good fertility-sparing procedure can be performed only in young women at early stages of disease, when the wish for childbearing is not yet fulfilled. Copyright © 2017 The Authors. Published by Wolters Kluwer Health, Inc. All rights reserved.

Comparison between laparotomy first versus angiographic embolization first in patients with pelvic fracture and hemoperitoneum: a nationwide observational study from the Japan Trauma Data Bank

PubMed Central

2013-01-01

Background A common dilemma in the management of pelvic fractures is recognizing the presence of associated abdominal injury. The purpose of this study was to determine the association between initial therapeutic intervention (laparotomy or transcatheter arterial embolization (TAE)) and mortality. Methods This was a cohort study using the Japan Trauma Data Bank between 2004 and 2010, including blunt trauma patients with pelvic fractures and positive Focused Assessment with Sonography in Trauma (FAST) results. Eligible patients were restricted to those who underwent laparotomy or TAE/angiography as the initial therapeutic intervention. Crude and adjusted odds ratio (AOR) for in-hospital mortality were compared between the laparotomy first and TAE first groups (reference group). Multiple logistic regression analysis and propensity score adjusted analysis were used to adjust for clinically relevant confounders, including the severity of injury. Results Of the 317 participants, 123 patients underwent laparotomy first and 194 patients underwent TAE first. The two groups were similar in terms of age, although the laparotomy first group had higher mean Injury Severity Scores (ISS) and higher mean scores based on the abdominal Abbreviated Injury Scale (AIS), as well as lower mean pelvic AIS and systolic blood pressure (SBP). Half of the patients who were hypotensive (SBP < 90 mmHg) on arrival underwent TAE first. The laparotomy first group had a significantly higher crude in-hospital mortality (41% vs. 27%; P < 0.01). After adjusting for confounders, the choice of initial therapeutic intervention did not affect the in-hospital mortality (AOR, 1.20; 95% Confidence Interval (CI), 0.61-2.39). Even in the limited subgroup of hypotensive patients (SBP 66–89 mmHg and SBP < 65 mmHg subgroup), the effect was similar (AOR, 1.50; 95% CI, 0.56-4.05 and AOR, 1.05; 95% CI, 0.44-3.03). Conclusions In Japan, laparotomy and TAE are equally chosen as the initial therapeutic intervention regardless of hemodynamic status. No significant difference was seen between the laparotomy first and TAE first groups regarding in-hospital mortality. PMID:24299060

Abdominal intra-compartment syndrome - a non-hydraulic model of abdominal compartment syndrome due to post-hepatectomy hemorrhage in a man with a localized frozen abdomen due to extensive adhesions: a case report.

PubMed

Bressan, Alexsander K; Kirkpatrick, Andrew W; Ball, Chad G

2016-09-15

Postoperative hemorrhage is a significant cause of morbidity and mortality following liver resection. It typically presents early within the postoperative period, and conservative management is possible in the majority of cases. We present a case of late post-hepatectomy hemorrhage associated with overt abdominal compartment syndrome resulting from a localized functional compartment within the abdomen. A 68-year-old white man was readmitted with sudden onset of upper abdominal pain, vomiting, and hemodynamic instability 8 days after an uneventful hepatic resection for metachronous colon cancer metastasis. A frozen abdomen with adhesions due to complicated previous abdominal surgeries was encountered at the first intervention, but the surgery itself and initial recovery were otherwise unremarkable. Prompt response to fluid resuscitation at admission was followed by a computed tomography of his abdomen that revealed active arterial hemorrhage in the liver resection site and hemoperitoneum (estimated volume <2 L). Selective arteriography successfully identified and embolized a small bleeding branch of his right hepatic artery. He remained hemodynamically stable, but eventually developed overt abdominal compartment syndrome. Surgical exploration confirmed a small volume of ascites and blood clots (1.2 L) under significant pressure in his supramesocolic region, restricted by his frozen lower abdomen, which we evacuated. Dramatic improvement in his ventilatory pressure was immediate. His abdomen was left open and a negative pressure device was placed for temporary abdominal closure. The fascia was formally closed after 48 hours. He was discharged home at postoperative day 6. Intra-abdominal pressure and radiologic findings of intra-abdominal hemorrhage should be carefully interpreted in patients with extensive intra-abdominal adhesions. A high index of suspicion and detailed understanding of abdominal compartment mechanics are paramount for the timely diagnosis of abdominal compartment syndrome in these patients. Clinicians should be aware that abnormal anatomy (such as adhesions) coupled with localized pathophysiology (such as hemorrhage) can create a so-named abdominal intra-compartment syndrome requiring extra vigilance to diagnose.

Emergency treatment of violent trauma: clinical cases and surgical treatment of penetrating thoracoabdominal, perineal and anorectal trauma.

PubMed

Zuccon, William; Paternollo, Roberto; Del Re, Luca; Cordovana, Andrea; De Murtas, Giovanni; Gaverini, Giacomo; Baffa, Giulia; Lunghi, Claudio

2013-01-01

The authors analyse clinical cases of penetrating thoracic, abdominal, perineal and anorectal injury and describe the traumatic event and type of lesion, the principles of surgical treatment, the complication rate and follow up. In the last 24 months, we analyzed 10 consecutive cases of penetrating thoracic and abdominal wounds [stab wound (n=7), with evisceration (n=4), gunshot wound (n=1)], and penetrating perineal and anorectal wounds (impalement n=4). In addition, we report an unusual case of neck injury from a stab wound. All the patients underwent emergency surgery for the lesions reported. In 7 cases of perforating vulnerant thoracoabdominal trauma from stab wounds there was hemoperitoneum due to bleeding from the abdominal wall (n=3), the omentum (n=1), the vena cava (n=1) and the liver (n=2). Evisceration of the omentum was observed in 4 cases. In 2 cases laparoscopy was performed. In one case laparotomy and thoracoscopy was performed. In a patient with an abdominoperineal gunshot wound, exploration was extraperitoneal. The 4 cases of perineal and anorectal impalement were treated with primary reconstruction, while in one case a laparotomy was needed to suture the rectum and fashion a temporary colostomy. In one case of anorectal injury rehabilitation resulted in a gradual improvement of fecal continence, while in the patient with the colostomy follow up at 2 months was scheduled to plan colostomy closure. Based on the our clinical experience and the literature, in penetrating abdominal trauma laparotomy may be required if patients are hemodynamically unstable (or in hemorrhagic shock), in patients with evisceration and peritonitis, or for exploration of penetrating thoracoabdominal and epigastric lesions. In anterior injuries of the abdominal wall from gunshot or stab wounds, laparotomy is indicated when there is peritoneal violation and significant intraperitoneal damage. In patients with actively bleeding wounds of the abdominal wall muscles minimal laparotomy is often necessary for control of hemorrhage and abdominal wall reconstruction to avoid herniation. If patients are asymptomatic, in cases of anterior lesions the indications for diagnostic laparoscopy are uncertain. Selective conservative treatment is reserved for asymptomatic patients who are hemodynamically stable. Further controlled studies are needed. Early surgery for perineal and anorectal trauma, and also for complex injuries, is the gold standard for treatment.

Risk of bleeding with dabigatran in atrial fibrillation.

PubMed

Hernandez, Inmaculada; Baik, Seo Hyon; Piñera, Antonio; Zhang, Yuting

2015-01-01

It remains unclear whether dabigatran etexilate mesylate is associated with higher risk of bleeding than warfarin sodium in real-world clinical practice. To compare the risk of bleeding associated with dabigatran and warfarin using Medicare data. In this retrospective cohort study, we used pharmacy and medical claims in 2010 to 2011 from a 5% random sample of Medicare beneficiaries. We identified participants as those newly diagnosed as having atrial fibrillation from October 1, 2010, through October 31, 2011, and who initiated dabigatran or warfarin treatment within 60 days of initial diagnosis. We followed up patients until discontinued use or switch of anticoagulants, death, or December 31, 2011. Dabigatran users (n = 1302) and warfarin users (n = 8102). We identified any bleeding events and categorized them as major and minor bleeding by anatomical site. Major bleeding events included intracranial hemorrhage, hemoperitoneum, and inpatient or emergency department stays for hematuria, gastrointestinal, or other hemorrhage. We used a propensity score weighting mechanism to balance patient characteristics between 2 groups and Cox proportional hazards regression models to evaluate the risk of bleeding. We further examined the risk of bleeding for 4 subgroups of high-risk patients: those 75 years or older, African Americans, those with chronic kidney disease, and those with more than 7 concomitant comorbidities. Dabigatran was associated with a higher risk of bleeding relative to warfarin, with hazard ratios of 1.30 (95% CI, 1.20-1.41) for any bleeding event, 1.58 (95% CI, 1.36-1.83) for major bleeding, and 1.85 (95% CI, 1.64-2.07) for gastrointestinal bleeding. The risk of intracranial hemorrhage was higher among warfarin users, with a hazard ratio of 0.32 (95% CI, 0.20-0.50) for dabigatran compared with warfarin. Dabigatran was consistently associated with an increased risk of major bleeding and gastrointestinal hemorrhage for all subgroups analyzed. The risk of major bleeding among dabigatran users was especially high for African Americans and patients with chronic kidney disease. Dabigatran was associated with a higher incidence of major bleeding (regardless of the anatomical site), a higher risk of gastrointestinal bleeding, but a lower risk of intracranial hemorrhage. Thus, dabigatran should be prescribed with caution, especially among high-risk patients.

Minimal invasive treatment of life-threatening bleeding caused by cardiopulmonary resuscitation-associated liver injury: a case report.

PubMed

Næss, Pål Aksel; Engeseth, Kristian; Grøtta, Ole; Andersen, Geir Øystein; Gaarder, Christine

2016-05-29

Life-threatening bleeding caused by liver injury due to chest compressions is a rare complication in otherwise successful cardiopulmonary resuscitation. Surgical intervention has been suggested to achieve bleeding control; however, reported mortality is high. In this report, we present a brief literature review and a case report in which use of a less invasive strategy was followed by an uneventful recovery. A 37-year-old white woman was admitted after out-of-hospital cardiac arrest. Bystander cardiopulmonary resuscitation was immediately performed, followed by advanced cardiopulmonary resuscitation that included tracheal intubation, mechanical chest compressions, and external defibrillation with return of spontaneous circulation. Upon hospital admission, the patient's blood pressure was 94/45 mmHg and her heart rate was 110 beats per minute. Her electrocardiogram showed no signs of ST-segment elevations or Q-wave development. Coronary angiography revealed a proximal thrombotic occlusion of the left anterior descending coronary artery. Successful recanalization, after thrombus aspiration and balloon dilation followed by stent implant, was verified with normalized anterograde flow. Immediately after the patient's arrival in the intensive cardiac care unit, a drop in her blood pressure to 60/30 mmHg and a hemoglobin concentration of 4.5 g/dl were noticed. Transfusion was started, and bedside abdominal ultrasound examination revealed free intraperitoneal fluid. Computed tomography of the abdomen revealed liver injury with active extravasation from the cranial surface of the right lobe and a massive hemoperitoneum. The patient was coagulopathic and acidotic with a body temperature of 33.5 °C. A minimally invasive treatment strategy, including angiography and selective trans-catheter arterial embolization, were performed in combination with percutaneous evacuation of 4.5 L of intraperitoneal blood. After completion of these procedures, the patient was hemodynamically stable. She was weaned off mechanical ventilation 2 days later and made an uneventful recovery. She was discharged to a local hospital on day 13 without neurological disability. Although rare, bleeding caused by liver injury due to chest compressions can be life-threatening after successful cardiopulmonary resuscitation. Reported mortality is high after surgical intervention, and patients may benefit from less invasive treatment strategies such as those presented in this case report.

[National project for the clinical management of healthcare processes. The surgical treatment of cholelithiasis. Development of a clinical pathway].

PubMed

Villeta Plaza, R; Landa García, J I; Rodríguez Cuéllar, Elías; Alcalde Escribano, J; Ruiz López, Pedro

2006-11-01

Because surgical treatment of gallstones is highly prevalent, this topic is particularly suitable for a national study aimed at determining the most important indicators and developing a clinical pathway. To analyze the results obtained during the hospital phase of the process. To define the key indicators of the process. To design a clinical pathway for laparoscopic cholecystectomy. A multicenter, prospective, cross-sectional, descriptive study was performed of patients who consecutively underwent surgery for gallstones in 2002. The sample size calculated with data provided by the National Institute of Statistics was 304 patients, which was increased by 45% to compensate for possible losses. Inclusion criteria consisted of elective cholecystectomy for gallstones, without preoperative findings suggestive of common duct stones. A database was designed (Microsoft Access 2000) with 76 variables analyzed in each patient. Completed questionnaires were obtained from 37 hospitals with 426 patients. The mean age was 55.69 years, with a predominance of women (68.3%). The most frequent symptom was biliary colic (23%). A total of 20.3% of the patient had prior episodes of cholecystitis and 18% had a history of mild pancreatitis. Diagnosis was given by ultrasonography in 93.2% of the patients. Informed consent was provided by 93.2%. The intervention was performed on an inpatient basis in 96.1% and in the ambulatory setting in the remainder. Antibiotic and antithrombotic prophylaxis was administered in 78.9% and 75.1% of the patients respectively. The laparoscopic approach was used in 84.6%, with a conversion rate of 4.9%. Intraoperative cholangiography was performed in 17.8% of the patients and common duct stones were found in 7 patients. The most frequent complication was surgical wound infection (1.1%). Possible accidental lesion of the biliary tract occurred in 0.7% of the patients and was described as biliary fistula. There were four reinterventions: biliary fistula (1), hemoperitoneum (2) and cause unknown (1). The mean surgical time was 73.17 minutes, with a median of 60 minutes. Postoperative length of stay was 4.75 days in open surgery and 2.67 days in laparoscopic surgery. Ninety-nine percent of the patients were satisfied or highly satisfied with the healthcare received. Analysis of the process and review of the literature identified a series of areas requiring improvement, which were gathered in the clinical pathway developed. These areas consisted of increasing the number of patients with correctly indicated antibiotic and antithrombotic prophylaxis, increasing the percentage of patients providing informed consent and undergoing adequate preoperative tests, limiting intraoperative cholangiography to selected patients, and reducing the number of patients with an overall stay of 3 days.