Perforated Meckel’s Diverticulum with Pancreatic and Gastric Heterotropia and Acute Peritonitis - A Case Report

Meckel’s diverticulum, the most common congenital anomaly of small bowel although usually silent, can cause complications like intestinal obstruction, bleeding, diverticulitis, perforation etc. We report a case, which presented with acute onset of severe pain in right iliac fossa which was clinically and sonographically diagnosed as acute appendicitis. Histopathological report of appendix was non specific findings. Four days after appendectomy patient again came with features of acute abdomen. X-ray abdomen showed free gas under diaphragm. Abdomen was explored with a midline incision, a perforated Meckel’sdiverticulum was found which was managed by wedge resection and repair of the ileum. Histopathological examination of specimen revealed diverticular wall with normal appearing intestinal mucosa and muscle coat which showed two heterotrophic tissues (pancreatic and gastric ) in the wall.These also showed features of perforation and acute peritonitis. This is probably the first case of Meckel’s diverticulitis with heterotropic pancreatic and gastric tissue in Bangladesh. J Shaheed Suhrawardy Med Coll 2020; 12(2): 115-118

A Curious “Appendicitis”, Magnetic Foreign Bodies Ingestion In a Five Year Old Girl With Ileal Perforation. Case Report and Review of Literature.

BackgroundForeign body ingestion is common in children. Ingestion of multiple magnetic foreign bodies poses a significant risk of complications as they are unlikely to pass spontaneously. Case presentationWe present our interesting case of a 5 Year old girl, complaining of right iliac fossa pain not relieved with paracetamol, associated with 2 episodes of vomiting and one episode of loose bowel motion. Abdominal examination revealed tender right iliac fossa with weak rebound and mild guarding with no rigidity. WBC was 16.9, with 12.68 neutrophils, with normal urea, creatinine, amylase, CRP and liver function tests. Patient was admitted for suspected appendicitis versus gastroenteritis. Abdominal ultrasound showed free fluid in the pelvis, appendix was not seen and there was a mass in the right iliac fossa. The patient was started on intravenous co-amoxiclav and diagnostic laparoscopy revealed a normal appendix with free fluid in pelvis. The omentum was stuck to terminal ileum with two necrotic patches and a perforation in the terminal ileum with magnetic foreign bodies protruding from the perforation site.There was no peritoneal contamination. Laparotomy was performed via right lower transverse incision with resection & anastomosis of necrotic perforated bowel segment and removal of three magnetic foreign bodies from the terminal ileum. Patient had smooth postoperative recovery. ConclusionThe Ingestion of multiple magnets, or a magnet with a metallic object should be considered an impending surgical emergency as it is unlikely to pass spontaneously and complications are more likely. There are no reports where more than one magnet was passed spontaneously. The possibility of foreign body ingestion should always be considered in a young child presenting with abdominal symptoms. Early intervention is indicated if the history, clinical findings and imaging are suggestive of multiple magnetic ingestion to prevent serious life threatening complications.

An unusual case of right iliac fossa lump-spigelian hernia: a case report

Spigelian hernia is a relatively uncommon hernia of anterior abdominal wall, occurring in different anatomical tissue planes. It is a variant of inter-parietal hernia. Preoperative diagnosis of obstructed inter-parietal hernia is based on imaging. Once correctly diagnosed it is easily amenable to surgical repair. We present a case of Spigelian hernia presenting as right iliac fossa lump with features of small bowel obstruction.

Evaluation of Analgesia Effect after Ultrasound-Guided Laparoscopic Renal Surgery

Kidney surgery involves placing the kidney in the iliac fossa of the lower abdomen on the right or left side. Studies have found that most kidney patients experience moderate to severe pain after surgery. The stress response caused by postoperative pain, especially visceral pain, not only aggravates the patient’s pain and irritability and aggravates the original complications but may also harm the early recovery of renal function and affect the survival of the kidney. Therefore, adequate postoperative analgesia for renal patients is essential. This paper combines ultrasound-guided laparoscopic technology to improve the postoperative analgesia effect of renal surgery and compares the data with experimental research methods. Through experimental research, it can be seen that the method proposed in this article has a certain effect, and ultrasound-guided laparoscopic technology can be used in follow-up clinical research to improve the analgesic effect of renal surgery.

En-Bloc Transplantation of Dual Adult Kidneys with Multiple Vessels

Background. To provide optimal nephron mass, two adult kidneys with suboptimal function can be transplanted into one single recipient. All techniques described to date are based on the lengthy sequential transplantation of one allograft after the other, in each iliac fossa, or through one long incision in the right iliac quadrant. Material and Methods. We report on a novel shorter and simpler operative technique allowing the en-bloc transplantation of seven dual adult kidneys with multiple vessels into a single iliac fossa, with revascularization through the donor aorta and vena cava. A proposal for the identification, allocation, procurement, and placement of the dual adult kidneys is presented. Results. There was no primary non-function, no thrombosis, and no urinary leakage. No urosepsis and hydronephrosis were noted during the follow-up. The operative time was 180 min. At 36 months, serum creatinine levels averaged 1.8 mg/dL (range 1.4–1.9 mg/dL). Conclusions. The procedure described permits converting two complex vascular kidneys into one en-bloc graft, which then can be transplanted into a single iliac incision, using only one arterial and one venous anastomoses. It avoids extensive dissection, shortens the operative time, and reduces the complications rate for the elderly recipients. It is applicable to the transplantation of dual kidneys with single or multiple arteries.

Exercise-induced ruptured renal tumour in a young patient with hereditary leiomyomata-associated renal cell carcinoma (HLRCC): a case report

Background Hereditary leiomyomatosis-associated renal cell carcinoma (HLRCC) is rare with only 300 families reported to date worldwide. Despite highlighting renal malignancy, it is infamous for its cutaneous and leiomyomatosis component as the more common cause of presentation. This report is to highlight the rare presentation of HLRCC which occurs in a teenager which is unfortunately complicated with exercise-induced renal tumour rupture. Case presentation A 22-year-old gentleman presented with severe right lower abdominal pain for 4 days, associated with fever and nausea following a session of strenuous exercise. He has first-degree relatives and second-degree relatives from his maternal side who were genetically tested positive for HLRCC. Clinical examination revealed a tender right lumbar and right iliac fossa region. A computed tomography of the kidneys demonstrated a ruptured right renal tumour with a large right renal subcapsular and contained right retroperitoneal hematoma. An emergency right radical nephrectomy was performed, and he recovered well. The histopathological examination was consistent with HLRCC associated ruptured right renal cell carcinoma. Conclusion Identification of this underreported familial malignancy is paramount as the onset of neoplasia occurs much earlier in life. This necessitates screening of family members at a younger age, and the management is followed by life-long surveillance.

Ovarian vein thrombosis: a rare but not to be forgotten cause of abdominal pain

A healthy 38-year-old woman, with no significant medical or surgical history, was referred to the gynaecology emergency department with acute low quadrant abdominal pain and nausea. On examination, painful palpation of right iliac fossa, abdominal guarding and positive Blumberg’s sign were noted. An abdominal-pelvic CT scan showed a hypodense tubular structure with peripheral enhancement to the right of the inferior vena cava, suggestive of thrombosis of the right ovarian vein. The only risk factor identified was the use of the combined contraceptive pill.

The management of appendicular abscesses in a Tunisian Tertiary Care Hospital

Background This study aims to describe the epidemiological, clinical, and radiological features of appendicular abscesses, compare the different approaches, and assess the safety and utility of laparoscopy in its management. Methods This descriptive retrospective study was carried out over 3 years extending from January 2017 to December 2019, reporting 150 appendicular abscesses cases. Data were collected from the register of the general surgery department B of the Rabta hospital. Cases with appendicular abscess were included. Files concerning patients with early appendicitis, non-appendicular abscesses or generalized appendicular peritonitis were excluded. Data were analysed with Statistical Package for the Social Sciences (SPSS) software. In univariate analysis, we used the chi2 test, the Fischer test, the Student t test. The factors retained by the univariate analysis were introduced into a logistic regression model. The significance level was set to 0.05. Results The mean age was 40.51 years. The gender ratio in patients with appendicular abscesses was M:F 1.94:1. Pain in the right iliac fossa associated with fever was the most common symptom (78% of cases). Clinical examination showed tenderness in the right iliac fossa in 38% of cases, rebound and guarding were found in 77 patients (51.3%), and a palpable mass was noted in 4 cases (4.2%). Imaging was done to confirm diagnosis; 46 patients underwent ultrasonogram and this confirmed the diagnosis in 26 patients (56%), while among the 71 patients who underwent CT abdomen confirmatory diagnosis was made in 65 patients (91.55%). An appendectomy was performed in 148 patients (98.6%) via laparoscopic approach in 94 patients, open Mac burney procedure in 32 cases (21.3%) and midline incision in 24 cases (16%). Two patients had an ileocecal resection. The appendix was most commonly located retrocecally (55.3%) in our cohort. The laparoscopic approach was performed in 94 patients (62.6%), and we had to convert in 44 patients due to dissection difficulties (46.8%). Among patients who underwent laparascopic approach 7 had developed peritonitis.. There were only 2 deaths. The mortality rate was 0,013%. The median duration of outpatient followup was 6 months (4–24 weeks) and was uneventful. Conclusion Appendicular abscess is a disease of young adults more common in men. Location of the appendix in our case series was mostly retroceacal. Laparoscopy was associated with good outcomes; peritonitis was uncommon and mortality was rare. The laparoscopic approach is a safe surgical technique for treating appendicular abscess and it can be considered as the routine approach for this condition In developing countries with limited technical resources, laparoscopy guarantees the absence of recurrence, reduces healthcare costs and decreases the risk of treating a severe disease conservatively.