Isolated Jejunal Perforation and Mesentery Injury following a Kick on the Abdomen of a College Student: A Case Report from a District Hospital in Northern Ghana

Introduction. Isolated jejunal perforation from blunt abdominal trauma is an extremely rare intra-abdominal injury that poses a huge diagnostic challenge. Delay in diagnosis and initiation of treatment often leads to significant morbidity and mortality. Diagnosis particularly in resource-poor settings may be extremely challenging and often relies on a high index of suspicion. This is due to lack of adequate diagnostic facilities and human resource to deal with the condition with resulting high occurrence of adverse outcomes. Case Presentation. We report a case of isolated jejunal perforation with associated mesentery injury in a young college student who sustained a kick to his abdomen while playing soccer. This is an unusual presentation since most reported cases often resulted from motor vehicular accidents, bicycle handlebar, and fall from a height. We emphasized the role of critical level of suspicion with a good history and physical examination as the major source of diagnosis since diagnostic procedures, such as abdominal ultrasonography and computed tomography, are largely unavailable in most resource-constraint settings. Early surgical intervention following diagnosis leads to good recovery and reduced mortality. Conclusion. Sufficient vigilance and suspicions of small bowel perforation should always be considered after blunt trauma even when symptoms and physical findings are minimal and when diagnostic capacity is limited.

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Fractures of the scaphoid, diagnosis and managementa review

Acta chirurgica iugoslavica ◽

10.2298/aci1302099a ◽

2013 ◽

Vol 60 (2) ◽

pp. 99-102 ◽

Cited By ~ 3

Author(s):

Sladjana Andjelkovic ◽

Cedo Vuckovic ◽

Aleksandar Lesic ◽

Goran Tulic ◽

Suzana Milutinovic ◽

...

Keyword(s):

Scaphoid Fracture ◽

Delayed Union ◽

Adverse Outcomes ◽

Scaphoid Bone ◽

Wrist Injuries ◽

Delay In Diagnosis ◽

Scaphoid Fractures ◽

Radiocarpal Joint ◽

High Index Of Suspicion ◽

Loss Of Motion

The scaphoid is vitally important for the proper mechanics of wrist function. Fracture of the scaphoid bone is the most common carpal fracture. Among all wrist injuries the incidence of scaphoid fracture is second only to fractures of the distal radius. Scaphoid fractures are significant because a delay in diagnosis can lead to a variety of adverse outcomes that include nonunion, delayed union, decreased grips strength, range of motion and osteoarthritis of the radiocarpal joint. To avoid missing this diagnosis, a high index of suspicion and a through history and physical examination are necessary, because initial radiographs are often negative. Regardless of the technique of bone grafting, there will almost always be some loss of motion even if the fracture unites.

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Multiple spontaneous jejunal and ileal perforations: a diagnostic challenge

International Surgery Journal ◽

10.18203/2349-2902.isj20210980 ◽

2021 ◽

Author(s):

Vijayalakshmi Sunder ◽

Shanthi Ponandal Swaminathan ◽

Vikas Kawarat ◽

Kamalraj Maiyazhagan ◽

Shriram Khanna ◽

...

Keyword(s):

Bowel Resection ◽

Histopathological Examination ◽

Bowel Perforation ◽

Fatal Outcome ◽

Small Bowel Perforation ◽

Diagnostic Challenge ◽

Active Pulmonary Tuberculosis ◽

High Index Of Suspicion ◽

Tuberculosis Therapy ◽

Mucous Fistula

Spontaneous multiple jejunal perforations are rare. In India, the commonest cause of small bowel perforation is typhoid fever followed by tuberculosis. We report a case of multiple jejunal and ileal perforations in a 23-year-old young woman who was known to have ulcerative colitis on medical therapy including steroids. She was then diagnosed to have active pulmonary tuberculosis and commenced on anti-tuberculosis therapy. She presented with generalised peritonitis and underwent emergency bowel resection with proximal enterostomy and creation of mucous fistula of the distal ileum. Post-operative course was stormy due to sepsis and she eventually succumbed on the 3rd post-operative day. Histopathological examination revealed non-specific changes and was not contributory to diagnosis. Possible causes of spontaneous jejunal perforations are discussed and the literature is reviewed. This case, despite a fatal outcome, is being reported to highlight the need for high index of suspicion in such situations.

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The interplay of Clostridioides difficile infection and inflammatory bowel disease

Therapeutic Advances in Gastroenterology ◽

10.1177/17562848211020285 ◽

2021 ◽

Vol 14 ◽

pp. 175628482110202

Author(s):

Kanika Sehgal ◽

Devvrat Yadav ◽

Sahil Khanna

Keyword(s):

Inflammatory Bowel Disease ◽

Bowel Disease ◽

Adverse Outcomes ◽

Molecular Tests ◽

Clostridioides Difficile ◽

Increased Risk ◽

Clostridioides Difficile Infection ◽

Pros And Cons ◽

Inflammatory Bowel ◽

High Index Of Suspicion

Inflammatory bowel disease (IBD) is a chronic disease of the intestinal tract that commonly presents with diarrhea. Clostridioides difficile infection (CDI) is one of the most common complications associated with IBD that lead to flare-ups of underlying IBD. The pathophysiology of CDI includes perturbations of the gut microbiota, which makes IBD a risk factor due to the gut microbial alterations that occur in IBD, predisposing patients CDI even in the absence of antibiotics. Superimposed CDI not only worsens IBD symptoms but also leads to adverse outcomes, including treatment failure and an increased risk of hospitalization, surgery, and mortality. Due to the overlapping symptoms and concerns with false-positive molecular tests for CDI, diagnosing CDI in patients with IBD remains a clinical challenge. It is crucial to have a high index of suspicion for CDI in patients who seem to be experiencing an exacerbation of IBD symptoms. Vancomycin and fidaxomicin are the first-line treatments for the management of CDI in IBD. Microbiota restoration therapies effectively prevent recurrent CDI in IBD patients. Immunosuppression for IBD in IBD patients with CDI should be managed individually, based on a thorough clinical assessment and after weighing the pros and cons of escalation of therapy. This review summarizes the epidemiology, pathophysiology, the diagnosis of CDI in IBD, and outlines the principles of management of both CDI and IBD in IBD patients with CDI.

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Unusual Nasogastric Tube Position Leading to Delay in Diagnosis of Tracheoesophageal Fistula

Journal of Neonatology ◽

10.1177/09732179211036778 ◽

2021 ◽

pp. 097321792110367

Author(s):

Monika Kaushal ◽

Saima Asghar ◽

Ayush Kaushal

Keyword(s):

Early Diagnosis ◽

Nasogastric Tube ◽

Common Type ◽

X Ray ◽

Delay In Diagnosis ◽

Atypical Symptoms ◽

Tube Position ◽

Esophageal Pouch ◽

High Index Of Suspicion ◽

Surgical Unit

Aim: This case highlights the importance of high index of suspicion for early diagnosis and thorough clinical examination of a newborn with tracheoesophageal atresia and fistula. Case Report: We report a case of most common type of tracheoesophageal atresia with fistula where diagnosis was missed due to unusual gastric position of nasogastric tube. Nasogastric tube reached stomach in esophageal atresia with fistula, delaying the diagnosis and management of condition. After accidental removal of tube and failure to pass again raised suspicion and was confirmed with coiled tube in esophageal pouch in X-Ray chest. Baby shifted to surgical unit for treatment, fortunately baby recovered and discharged home after surgical correction. Conclusion: Tracheoesophageal atresia with fistula can present with atypical symptoms and unusual events, challenging the early diagnosis and treatment of common types of conditions. Other association like VACTERL should be looked for, in patients.

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Abstract 13304: Liver Dispersion Predicts Adverse Outcomes in Patients With Heart Failure

Circulation ◽

10.1161/circ.142.suppl_3.13304 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Yu Hotsuki ◽

Akiomi Yoshihisa ◽

Koichiro Watanabe ◽

Yu Sato ◽

Yusuke Kimishima ◽

...

Keyword(s):

Heart Failure ◽

Cardiac Death ◽

Cardiac Event ◽

Liver Stiffness ◽

Adverse Outcomes ◽

Right Atrial ◽

Gamma Glutamyl Transferase ◽

Abdominal Ultrasonography ◽

Patients With Heart Failure ◽

Glutamyl Transferase

Background: It has been recently reported that liver stiffness assessed by transient elastography reflects right atrial pressure (RAP), and is associated with worse outcome in patients with heart failure (HF). However, the relationship between liver dispersion (LD, a novel indicator of liver viscosity) determined by abdominal ultrasonography and RAP, and prognostic impacts of LD on HF patients have not been fully examined. We aimed to clarify associations of LD with parameters of liver functional test (LFT) and right-heart catheterization (RHC), and cardiac event such as cardiac death and worsening HF in patients with HF. Methods and Results: We performed abdominal ultrasonography, LFT, RHC, and followed up cardiac events including cardiac death and unplanned hospitalization due to HF in patients with HF (n=157). We examined associations of LD with parameters of LFT and RHC. There were significant correlations between LD and circulating levels of gamma-glutamyl transferase (R=0.197, P=0.018), cholinesterase (R=-0.301, P=0.001), and 7S domain of collagen type IV (P4NP 7S, a marker of fibrosis, R=0.334, P<0.001), but not with RAP (R=0.067, P=0.514) or cardiac index (R=-0.038, P=0.667). During the follow up period (median 305 days), 6 cardiac deaths and 18 unplanned hospitalization due to HF occurred. In the Kaplan-Meier analysis ( Figure ), cardiac event rate was significantly higher in the high LD group (LD ≥10.0 (m/s)/kHz, n=79) than in the low LD group (LD < 10.0 (m/s)/kHz, n=78; log-rank, P=0.007). In the multivariable Cox proportional hazard analysis, high LD was found to be an independent predictor of cardiac event (hazard ratio 3.274, 95% confidence interval 1.203-8.912, P=0.020). Conclusions: LD assessed by abdominal ultrasonography reflects liver fibrosis rather than liver congestion, and is associated with adverse prognosis in HF patients.

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Pompe Disease: Cyanosed Hypotonic Infant with Normal Respiratory Rate

Kathmandu University Medical Journal ◽

10.3126/kumj.v13i2.16794 ◽

2017 ◽

Vol 13 (2) ◽

pp. 172-174 ◽

Cited By ~ 1

Author(s):

S. Koirala ◽

A. Poudel ◽

R. Basnet ◽

K. Subedi

Keyword(s):

Respiratory Rate ◽

Pompe Disease ◽

Clinical Findings ◽

Diagnostic Challenge ◽

Floppy Infant ◽

History Of ◽

Infantile Pompe Disease ◽

High Index Of Suspicion ◽

To Receive ◽

Remote Part

Infantile hypotonia or floppy infant is a diagnostic challenge when it presents with other presenting complaints such as fever, cough or diarrhea. Many times the hypotonia goes unnoticed when other symptom covers the hypotonia and child continues to receive the treatment for other symptoms. We report a rare case from Nepal of infantile Pompe disease who presented with the history of fever and cough in the recent earthquake disaster camp at remote part of Sindhupalchowk, Nepal. He was being treated as a case of pneumonia.Pompe disease can be diagnosed clinically by taking detailed history and correlating the clinical findings during the presentation with other symptoms. In our case the normal respiratory rate, reduced Spo2 and presence of crackles dominated the hypotonia and was mistreated as pneumonia. High index of suspicion is necessary in diagnosing Pompe disease.

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Ileocolic intussusception as a presenting sign of primary lymphoma of the colon

Srpski arhiv za celokupno lekarstvo ◽

10.2298/sarh1110673n ◽

2011 ◽

Vol 139 (9-10) ◽

pp. 673-676 ◽

Cited By ~ 1

Author(s):

Milica Nestorovic ◽

Goran Stanojevic ◽

Vesna Brzacki ◽

Vesna Milojkovic ◽

Branko Brankovic ◽

...

Keyword(s):

Malignant Neoplasm ◽

Radical Resection ◽

Right Hemicolectomy ◽

Primary Lymphoma ◽

Ileocolic Intussusception ◽

Diagnostic Challenge ◽

Abdominal Ultrasonography ◽

Atypical Symptoms ◽

Colorectal Lymphoma ◽

The Right

Introduction. Intussusception is a rare phenomenon in adults. It is caused mainly by malignant neoplasm. Primary lymphoma of the colon is a rare malignancy of the large intestine. The association of intussusception in adult and primary colorectal lymphoma is a diagnostic challenge, since they occur with a variety of atypical symptoms. Case Outline. We report a case of ileocolic intussusception in a 26-year-old man induced by primary lymphoma of the cecum. He was admitted to our hospital for incomplete intestinal obstruction. After thorough diagnostic work-up (plain abdominal radiography, abdominal ultrasonography, multi-slice computerized tomography, colonoscopy with biopsy), the patient underwent surgery. Intraoperative findings confirmed lymphoma as the cause of intussusception. The right hemicolectomy was carried out with end-to-side ileo-transverse anastomosis. Conclusion. Primary colorectal lymphomas should be considered in differential diagnosis of intussusceptions in adults. The treatment of choice is a radical resection where all oncological standards must be fulfilled.

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Challenges in the Diagnosis of Giant Cell Arteritis Before Visual Loss

Neurology and Neurobiology ◽

10.31487/j.nnb.2020.03.06 ◽

2020 ◽

pp. 1-5

Author(s):

Purnima Mehta ◽

Faaiq Hassan ◽

Muhammed Omar Qadir ◽

Shirish Dubey ◽

Sergio Pagliarini ◽

...

Keyword(s):

Giant Cell Arteritis ◽

Giant Cell ◽

Visual Loss ◽

Systemic Vasculitis ◽

The Elderly ◽

Common Type ◽

Atypical Presentation ◽

Delay In Diagnosis ◽

Atypical Presentations ◽

High Index Of Suspicion

Background: Giant cell arteritis (GCA) is the most common type of systemic vasculitis affecting the elderly. Ophthalmic presentations of GCA in particular can be difficult to identify prior to permanent visual loss occurring. Methods: Here, we present 3 challenging cases as a retrospective series to highlight the variable presentations of GCA with ophthalmic involvement, but GCA was not suspected due to atypical presentation. Results: Unfortunately, all 3 cases went on to develop visual loss in the affected eye due to a delay in diagnosis or treatment. The authors wish to highlight the challenges posed to the referring clinicians, when patients had systemic/ocular co-morbidities, which delayed the suspicion of GCA Conclusion with a Practical Point: Our cases highlight the variable presentations of this condition as well as the devastating ophthalmic implications that GCA can have. A high index of suspicion must be maintained; particularly in elderly patients with atypical presentations.

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Diffuse infiltrating retinoblastoma: A diagnostic conundrum

IP International Journal of Ocular Oncology and Oculoplasty ◽

10.18231/j.ijooo.2021.040 ◽

2021 ◽

Vol 7 (2) ◽

pp. 204-206

Author(s):

Harsha Bhattacharjee ◽

Aditi Mehta ◽

Dipankar Das ◽

Kasturi Bhattacharjee ◽

Manabjyoti Barman ◽

...

Keyword(s):

Family History ◽

Multimodal Imaging ◽

Positive Family History ◽

Neovascular Glaucoma ◽

Exudative Retinal Detachment ◽

Imaging Features ◽

Diagnostic Challenge ◽

Progressive Loss ◽

History Of ◽

High Index Of Suspicion

Diffuse infiltrating retinoblastoma (DIR) is characterized by absence of intraocular mass, lack of calcification. It may mimic inflammatory uveitis or exudative retinopathy. An eight-years-old boy presented with progressive loss of vision in left eye. Clinical evaluation revealed neovascular glaucoma with a yellow–gray fundal glow, exudative retinal detachment, subretinal exudation and telangiectatic vessels. The presentation was consistent with exudative retinopathy (Coat’s disease) but for the presence of a family history of retinoblastoma in the younger sibling. Despite the absence of an intraocular mass or calcification on multimodal imaging, the enucleation was done on the basis of clinical suspicion of retinoblastoma. Histopathology confirmed a diagnosis of DIR.: DIR can pose a diagnostic challenge due to its non-characteristic clinical and imaging features and atypical presentation. A high index of suspicion along with a positive family history was key to diagnosis in our case; histopathology was confirmatory.

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Relapsing Tumefactive Demyelination: A Case Report

Acta Medica Academica ◽

10.5644/ama2006-124.231 ◽

2018 ◽

Vol 47 (2) ◽

pp. 193

Author(s):

Ibrahim Omerhodžić ◽

Almir Džurlić ◽

Dino Lisica ◽

Nevena Mahmutbegović ◽

Maida Nikšić ◽

...

Keyword(s):

Multiple Sclerosis ◽

Case Report ◽

Female Patient ◽

Demyelinating Disease ◽

Diagnostic Procedures ◽

Young Female ◽

Diagnostic Challenge ◽

Fresh Frozen ◽

The Central Nervous System ◽

Tumorlike Lesion

Objective. We present a case of relapsing tumefactive demyelination in a young female patient, that posed a real diagnostic challenge, with a heterogeneous clinical picture, atypical for multiple sclerosis (MS) presentation, and neuroradiological manifestations with a high suspicion of neoplastic diseases.Case Report. An 18-year old female patient presented to our Neurosurgical Out-patients’ Clinic with symptoms atypical for multiple sclerosis, unremarkable neurological deficit, one tumefactive lesion on MRI, followed by relapse and another two lesions within a period of six months. We decided to perform biopsy of the tumefactive lesion with compressive effect. Serological and clinical data were negative for MS, and the patient did not respond well to corticosteroid therapy. Fresh frozen tumor tissue aroused a strong suspicion of gemistocytic astrocytoma, so total resection was done, but the definitive pathohistological examination confirmed tumefactive demyelination.Conclusion. For clinicians, it is important to consider demyelinating disease in the differential diagnosis of a tumorlike lesion of the central nervous system, in order to avoid invasive and potentially harmful diagnostic procedures, especially in younger patients.

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