Anorectal emergencies: WSES-AAST guidelines

AbstractAnorectal emergencies comprise a wide variety of diseases that share common symptoms, i.e., anorectal pain or bleeding and might require immediate management. While most of the underlying conditions do not need inpatient management, some of them could be life-threatening and need prompt recognition and treatment. It is well known that an incorrect diagnosis is frequent for anorectal diseases and that a delayed diagnosis is related to an impaired outcome. This paper aims to improve the knowledge and the awareness on this specific topic and to provide a useful tool for every physician dealing with anorectal emergencies.The present guidelines have been developed according to the GRADE methodology. To create these guidelines, a panel of experts was designed and charged by the boards of the World Society of Emergency Surgery (WSES) and American Association for the Surgery of Trauma (AAST) to perform a systematic review of the available literature and to provide evidence-based statements with immediate practical application. All the statements were presented and discussed during the WSES-AAST-WJES Consensus Conference on Anorectal Emergencies, and for each statement, a consensus among the WSES-AAST panel of experts was reached. We structured our work into seven main topics to cover the entire management of patients with anorectal emergencies and to provide an up-to-date, easy-to-use tool that can help physicians and surgeons during the decision-making process.

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Immune checkpoint inhibitor combination therapies very frequently induce secondary adrenal insufficiency

Scientific Reports ◽

10.1038/s41598-021-91032-6 ◽

2021 ◽

Vol 11 (1) ◽

Author(s):

Katsunori Manaka ◽

Junichiro Sato ◽

Maki Takeuchi ◽

Kousuke Watanabe ◽

Hidenori Kage ◽

...

Keyword(s):

Combination Therapy ◽

Adrenal Insufficiency ◽

Cancer Patients ◽

Immune Checkpoint ◽

Checkpoint Inhibitors ◽

Delayed Diagnosis ◽

Secondary Adrenal Insufficiency ◽

Acth Deficiency ◽

Life Threatening ◽

Inhibitor Combination

AbstractImmune checkpoint inhibitors (ICIs) are potent therapeutic options for many types of advanced cancer. The expansion of ICIs use however has led to an increase in immune-related adverse events (irAEs). Secondary adrenal insufficiency (AI) can be life-threatening especially in patients with delayed diagnosis. We retrospectively investigated secondary AI in ICI-treated patients. A total of 373 cancer patients treated with ICIs were included and evaluated. An adrenocorticotropic hormone (ACTH) deficiency was described in 13 patients. Among 24 patients with a combination of nivolumab and ipilimumab therapy, 7 patients (29%) developed secondary AI in a median time of 8 weeks during the combination therapy and 2 of 15 patients (13%) developed isolated ACTH deficiency during maintenance nivolumab monotherapy following the combination therapy. More than half of the patients (4/7) with a combination therapy-induced multiple anterior hormone deficiencies was diagnosed as secondary AI based on regular ACTH and cortisol tests with slight subjective symptoms. Secondary AI can arise frequently and rapidly in cancer patients receiving a combination ICI therapy, and thus we speculate active surveillance of AI using regular ACTH and cortisol tests during the combination therapy might be useful for avoiding life-threatening conditions due to secondary AI.

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Atraumatic Splenic Rupture in a SARS-CoV-2 Patient: Case Report and Review of Literature

Case Reports in Surgery ◽

10.1155/2021/5553619 ◽

2021 ◽

Vol 2021 ◽

pp. 1-5

Author(s):

Marcello Agus ◽

Maria Elena Ferrara ◽

Paola Bianco ◽

Cristina Manieli ◽

Paolo Mura ◽

...

Keyword(s):

Abdominal Pain ◽

Splenic Rupture ◽

Delayed Diagnosis ◽

Caucasian Woman ◽

Threatening Condition ◽

Life Threatening ◽

Atraumatic Splenic Rupture ◽

Rupture Of The Spleen ◽

Delay Of Diagnosis ◽

Possible Cause

Splenic rupture in the absence of trauma or previously diagnosed disease is rare. Due to the delay of diagnosis and treatment, this is a potentially life-threatening condition. We report a case of atraumatic splenic rupture in a SARS-CoV-2 patient. This report is of particular interest as it first identifies SARS-CoV-2 infection as a possible cause of spontaneous rupture of the spleen. A 46-year-old Caucasian woman presented at the emergency department pale and sweaty, complaining of syncopal episodes, tachycardia, hypotension, diarrhea, intense abdominal pain, diffuse arthromyalgia, and fever from the day before. RT-PCR was positive for SARS-CoV-2 infection. CT scan demonstrated extensive hemoperitoneum due to rupture of the splenic capsule. The patient required an emergency open splenectomy because of an unresponsive hemorrhagic shock. At the end of the surgery, the patient was relocated to a COVID-19 dedicated facility. COVID-19 is a new disease of which all manifestations are not yet known. Inpatients affected by SARS-CoV-2 infection with abdominal pain and spontaneous splenic rupture should be considered to avoid a delayed diagnosis.

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Delayed diagnosis of bilateral subdural effusions complicating intracranial hypotension in a patient presenting with post lumbar puncture headache

BMJ Case Reports ◽

10.1136/bcr-2020-239559 ◽

2021 ◽

Vol 14 (2) ◽

pp. e239559

Author(s):

Saleheen Huq ◽

Menaka G Iyer ◽

Samson O Oyibo

Keyword(s):

Lumbar Puncture ◽

Delayed Diagnosis ◽

Bed Rest ◽

Viral Meningitis ◽

Magnetic Imaging ◽

Intracranial Complications ◽

Life Threatening ◽

History Of ◽

Discharge From Hospital ◽

Subdural Effusions

A 34-year-old woman presented with an unrelenting headache which had been ongoing since discharge from hospital 4 days before. She initially presented 2 weeks earlier with a 7 days history of severe headache, for which she had a CT scan, lumbar puncture and treatment for possible viral meningitis. The headache got worse 4 days after the lumbar puncture. Despite analgesics and bed rest, the headache persisted. A subsequent magnetic imaging scan demonstrated bilateral subdural effusions. She was given supportive treatment, which included advice concerning strict bed rest and analgesia. The headache took several months to abate. A third of patients suffer from post lumbar puncture headaches and this should be explained during informed consenting and post procedure. Not all post lumbar puncture headaches are simple headaches. A post lumbar puncture headache continuing for more than 7–14 days after the procedure requires further investigation to exclude life-threatening intracranial complications.

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Travel-Related Typhoid Fever: Narrative Review of the Scientific Literature

International Journal of Environmental Research and Public Health ◽

10.3390/ijerph17020615 ◽

2020 ◽

Vol 17 (2) ◽

pp. 615 ◽

Cited By ~ 1

Author(s):

Narcisa Muresu ◽

Giovanni Sotgiu ◽

Bianca Maria Are ◽

Andrea Cossu ◽

Clementina Cocuzza ◽

...

Keyword(s):

Low Income ◽

Delayed Diagnosis ◽

Low Income Countries ◽

Travel Health ◽

High Incidence ◽

Health Advice ◽

Life Threatening ◽

Risk Of Disease ◽

Resistant Strains ◽

Drug Resistant Strains

Enteric fever is a foodborne infectious disease caused by Salmonella enterica serotypes Typhi and Paratyphi A, B and C. The high incidence in low income countries can increase the risk of disease in travelers coming from high income countries. Pre-travel health advice on hygiene and sanitation practices and vaccines can significantly reduce the risk of acquiring infections. Although the majority of the cases are self-limiting, life-threatening complications can occur. Delayed diagnosis and cases of infections caused by multi-drug resistant strains can complicate the clinical management and affect the prognosis. More international efforts are needed to reduce the burden of disease in low income countries, indirectly reducing the risk of travelers in endemic settings. Surveillance activities can help monitor the epidemiology of cases caused by drug-susceptible and resistant strains.

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Haemoptysis

10.1093/med/9780199568741.003.0018 ◽

2018 ◽

Author(s):

Rakesh Panchal

Keyword(s):

Pulmonary Arteries ◽

Medical Emergency ◽

Haemodynamic Instability ◽

Respiratory Compromise ◽

Bronchial Arteries ◽

Specific Symptom ◽

Massive Haemoptysis ◽

Life Threatening ◽

Lung Condition ◽

Inpatient Management

Haemoptysis is the expectoration of blood or blood-stained sputum resulting from haemorrhage into the respiratory tract. Massive haemoptysis (5% of cases) is usually defined as >600 ml in 24 hours. Haemoptysis is a common and non-specific symptom. It can vary from blood-streaked sputum to massive, life-threatening haemorrhage. Haemoptysis may originate from the bronchial arteries (90%), pulmonary arteries (5%), or non-bronchial collaterals. Haemoptysis causing haemodynamic instability and/or respiratory compromise is a medical emergency. Unexplained haemoptysis may herald a serious underlying lung condition and therefore requires a thorough diagnostic workup. The majority of patients can be safely investigated and managed as outpatients. Urgent workup or inpatient management will be determined by the rate and severity of bleeding, and knowledge of either the source of bleeding and/or the underlying condition. This chapter covers the approach to diagnosis, diagnostic tests, therapies, prognosis, and dealing with uncertainty.

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Caesarean scar ectopic pregnancy

International Journal of Reproduction Contraception Obstetrics and Gynecology ◽

10.18203/2320-1770.ijrcog20181952 ◽

2018 ◽

Vol 7 (5) ◽

pp. 2038

Author(s):

T. Ramani Devi ◽

T. Sweta ◽

C. Archana Devi

Keyword(s):

Ectopic Pregnancy ◽

Conservative Management ◽

Abdominal Cavity ◽

Delayed Diagnosis ◽

Reproductive Age ◽

Mortality And Morbidity ◽

Caesarean Scar ◽

Future Fertility ◽

Laparoscopic Excision ◽

Life Threatening

Ectopic pregnancy is a common cause of mortality and morbidity among the women of reproductive age group. Tubal pregnancy is the commonest. It can occur in cervix, ovaries, previous caesarean scar, interstitial portion of the tube and abdominal cavity. Here we report a case of caesarean scar ectopic pregnancy which was managed conservatively. 31 yrs old gravid 3 previous 1 LSCS and 1 tubal ectopic come for antenatal consultation at 35 days of gestation. UPT was Positive. USG showed no evidence of intra uterine sac. Repeat scan after 10 days showed a gestational sac at the lower uterine segment scar. Hence it was decided for conservative management, injection methotrexate 50 mgm X 2 doses given. This was followed by misoprost vaginal insertion. Since patient did not expel the sac, injection PG F2 alpha 125 mg x 2 doses were given. Patient expelled the products of conception partially. This was followed by hysteroscopic guided evacuation.Caesarean scar ectopic was reported in 1978. Early diagnosis is by TV USG / MRI. Early ectopic can be treated medically. In delayed diagnosis, laparoscopic excision of the scar has to be done. In rupture of the scar site ectopic pregnancy laparotomy is indicated. In the event of heavy bleeding, hysterectomy has to be done. After conservative management and excision of the scar, fertility is not altered. Caesarean section scar pregnancy is a rare form of ectopic pregnancy which can lead to life threatening complications leading to mortality and morbidity. Treatment has to be individualized according to the gestational age, haemodynamic stability and desire for future fertility.

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Microbiological and clinical characteristics of cryptococcemia: a retrospective analysis of 85 cases in a Chinese hospital

Medical Mycology ◽

10.1093/mmy/myz089 ◽

2019 ◽

Vol 58 (4) ◽

pp. 478-484 ◽

Cited By ~ 1

Author(s):

Yiqi Fu ◽

Min Xu ◽

Hua Zhou ◽

Yake Yao ◽

Jianying Zhou ◽

...

Keyword(s):

Cerebrospinal Fluid ◽

Blood Culture ◽

Retrospective Analysis ◽

Clinical Characteristics ◽

Antifungal Susceptibility ◽

Delayed Diagnosis ◽

Sequence Type ◽

Lower Baseline ◽

Life Threatening ◽

Cryptococcus Spp

Abstract Cryptococcemia is a life-threatening fungal infection. Sometimes, it is hard to diagnose. The studies to describe the characteristics of cryptococcemia specifically were limited. We performed this retrospective analysis in a Chinese hospital during 2002–2015, including 85 cryptococcemia cases and 52 Cryptococcus spp. isolates. The species, mating type, antifungal susceptibility and multilocus sequence typing of Cryptococcus spp. were determined. C. neoformans var. grubii MATα of sequence type (ST) 5 is the representative strain of cryptococcemia, accounting for 51 isolates. The MIC50/90 values were 0.5/0.5, 1.0/1.0, 2.0/4.0, ≤0.06/0.25, and ≤0.06/≤0.06 μg/ml for amphotericin B, flucytosine, fluconazole, itraconazole, and voriconazole, respectively. Cryptococcemia was the first diagnostic proof of cryptococcosis in 37 patients (43.5%, 37/85). Compared with the patients initially diagnosed of cryptococcosis in other sites (mainly cerebrospinal fluid), the patients firstly diagnosed by blood culture had prolonged time from admission to diagnosis of cryptococcosis (9 days vs. 2 days, P < .001) and higher 30-day mortality (54.1% vs. 20.8%, P = .003), while fewer symptoms of meningitis (45.9% vs. 100%, P < .001). For the patients receiving lumbar puncture, the occurrence of meningitis was similar between the patients firstly diagnosed by blood culture and those firstly diagnosed in other sites (94.1% vs. 100%, P = .26). However, the patients first diagnosed by blood culture had lower baseline intracranial pressure (250 mm H2O vs. 342.5 mm H2O, P = .001). In conclusion, patients with cryptococcemia as the first diagnostic proof of cryptococcosis usually had neglected subtle symptoms of meningitis, which may result in delayed diagnosis and catastrophic outcome.

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Eating disorder or disordered eating: undiagnosed inflammatory bowel disease mimicking eating disorder

Archives of Disease in Childhood ◽

10.1136/archdischild-2018-316324 ◽

2018 ◽

Vol 104 (10) ◽

pp. 1004-1006

Author(s):

Rachel Elizabeth Harris ◽

Rachel Tayler ◽

Richard K Russell

Keyword(s):

Inflammatory Bowel Disease ◽

Eating Disorder ◽

Disordered Eating ◽

Bowel Disease ◽

Eating Habits ◽

Delayed Diagnosis ◽

Important Differential Diagnosis ◽

Gi Symptoms ◽

Incorrect Diagnosis ◽

Inflammatory Bowel

We describe the case of a patient with ongoing weight loss, low mood and previously undisclosed gastrointestinal (GI) symptoms initially diagnosed with an eating disorder and subsequently diagnosed with ulcerative colitis over a year following initial presentation. This patient exhibited disordered eating secondary to the worsening symptoms of undiagnosed inflammatory bowel disease (IBD) and had altered her eating habits to reduce the diarrhoea and rectal bleeding she was experiencing, contributing to significant weight loss.The implications of a delayed diagnosis of IBD or incorrect diagnosis of eating disorder are severe both physically and psychologically. We discuss factors in the assessment of patients which may raise suspicion of organic GI disease such as IBD—an important differential diagnosis in those with non-specific GI symptoms and suspected eating disorder—and highlight baseline investigations which should be performed to ensure a diagnosis of IBD is not missed in these patients.

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A Delayed Diagnosis: Conflicting Investigation Results Should Be Challenged

Case Reports in Pathology ◽

10.1155/2011/809567 ◽

2011 ◽

Vol 2011 ◽

pp. 1-4

Author(s):

D. Mital ◽

V. Desai

Keyword(s):

Clinical Picture ◽

Delayed Diagnosis ◽

Castleman’S Disease ◽

Expert Advice ◽

Multidisciplinary Teams ◽

Castleman's Disease ◽

Life Threatening ◽

Symptoms And Signs

We present a case where a diagnosis of advanced HIV led to many other diagnoses but more importantly life-threatening multivariant Castleman's disease which is rare and was successfully treated. This case highlights the importance of questioning and challenging investigations when it does not fit with the clinical picture. Multidisciplinary teams are crucial and always seek expert advice if unsure. The much-quoted adage of “many symptoms and signs will fit one diagnosis” also bodes well in this case.

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Primary care pediatricians’ interest in diagnostic error reduction

Diagnosis ◽

10.1515/dx-2015-0033 ◽

2016 ◽

Vol 3 (2) ◽

pp. 65-69 ◽

Cited By ~ 11

Author(s):

Michael L. Rinke ◽

Hardeep Singh ◽

Sarah Ruberman ◽

Jason Adelman ◽

Steven J. Choi ◽

...

Keyword(s):

Delayed Diagnosis ◽

Diagnostic Errors ◽

Diagnostic Error ◽

Error Reduction ◽

Self Report ◽

Abnormal Laboratory ◽

Electronic Survey ◽

Laboratory Values ◽

Life Threatening

Abstract: Diagnostic errors causing harm in children are understudied, resulting in a knowledge gap regarding pediatricians’ interest in reducing their incidence.: Electronic survey of general pediatricians focusing on diagnostic error incidence, errors they were interested in trying to improve, and errors reduced by their electronic health record (EHR).: Of 300 contacted pediatricians, 77 (26%) responded, 58 (19%) served ambulatory patients, and 48 (16%) completed the entire questionnaire. Of these 48, 17 (35%) reported making a diagnostic error at least monthly, and 16 (33%) reported making a diagnostic error resulting in an adverse event at least annually. Pediatricians were “most” interested in “trying to improve” missed diagnosis of hypertension (17%), delayed diagnosis due to missed subspecialty referral (15%), and errors associated with delayed follow-up of abnormal laboratory values (13%). Among the 44 pediatricians with an EHR, 16 (36%) said it reduced the likelihood of missing obesity and 14 (32%) said it reduced the likelihood of missing hypertension. Also, 15 (34%) said it helped avoid delays in follow-up of abnormal laboratory values. A third (36%) reported no help in diagnostic error reduction from their EHR.: Pediatricians self-report an appreciable number of diagnostic errors and were most interested in preventing high frequency, non-life-threatening errors. There exists a need to leverage EHRs to support error reduction efforts.

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