Spontaneous Gallbladdre Perforation: A case series

Background: Gallbladder is rarely injured as it is embedded in the liver and well protected by ribcage. Gallbladder perforation is a rare complication of acute calculus cholecystitis. Spontaneous gallbladder perforation is even rarer.Case Series: We present our experience of 4 cases of spontaneous gallbladder perforation. The patients were mostly males (3:1) with age ranging from 42-64 years. All the patients presented with abdominal pain, distension, ileus and fever ranging from 2-5 days duration. There was no prior history of biliary colic. Examination revealed abdominal tenderness and ileus. Abdominal radiographs showed multiple air-fluid levels and no pneumoperitoneum. Sonography and CT scan of abdomen revealed pericholecystic fluid, intra-abdominal collection with no evidence of gallstones. Provisional diagnosis was peritonitis in 3 and acute pancreatitis in one case. Image guided abdominal paracentesis yielded bilious fluid. In view of lack of clinical improvement and aspiration of bilious content all the patients were subjected to laparotomy. Gallbladder perforation in fundus region without stones and intra-abdominal bile collection was noted in all the patients. Cholecystectomy with peritoneal lavage and abdominal drainage was performed in all cases. Postoperative course was uneventful except wound infection in 2 cases. Histopathology report revealed features of acute cholecystitis in 2 and acute on chronic cholecystitis in the remaining 2 patients.Conclusion: Diagnosis of spontaneous gallbladder perforation should be suspected in middle aged patients who present with acute abdomen but does not have classical signs of peritonitis and in whom paracentesis has yielded bilious fluid.

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Labyrinthitis ossificans: How accurate is MRI in predicting cochlear obstruction?

Otolaryngology ◽

10.1016/j.otohns.2008.12.029 ◽

2009 ◽

Vol 140 (5) ◽

pp. 692-696 ◽

Cited By ~ 59

Author(s):

Brandon Isaacson ◽

Timothy Booth ◽

Joe W. Kutz ◽

Kenneth H. Lee ◽

Peter S. Roland

Keyword(s):

High Resolution ◽

Bacterial Meningitis ◽

Cochlear Implant ◽

Tertiary Care ◽

Fibrous Tissue ◽

Case Series ◽

Prior History ◽

Basal Turn ◽

Labyrinthitis Ossificans ◽

History Of

Objective: To determine the accuracy of preoperative MRI in predicting cochlear obstruction in pediatric patients with a history of bacterial meningitis. Methods: A case series with chart review was performed at a tertiary care multidisciplinary cochlear implant program. Forty-five children with hearing loss that resulted from bacterial meningitis were implanted from 1991 to 2006. Twenty-five children had preoperative MRI with high-resolution axial T2-weighted images to assess for cochlear patency. Results: Seventeen of 25 patients (68%) had surgical evidence of cochlear obstruction. Six patients (37.5%) required circummodiolar drill-outs, and one patient (6.25%) underwent placement of a double array cochlear implant. The nine remaining patients (56%) with cochlear obstruction required removal of fibrous tissue or drilling of the inferior basal turn, but did not require manipulation of the ascending basal turn to achieve full electrode insertion. The sensitivity, specificity, and positive and negative predictive value of MRI predicting intraoperative cochlear obstruction with 95 percent confidence intervals was 94.1 percent (71–99), 87.5 percent (47–99), 94.1 percent (71–99) and 87.5 percent (47–99), respectively. Conclusion: Preoperative high-resolution T2 MRI may be useful in predicting cochlear obstruction in patients with a prior history of bacterial meningitis.

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The “Fountain of Death”: A Case Series on Tracheo-innominate Artery Fistula

IIUM Medical Journal Malaysia ◽

10.31436/imjm.v20i2.727 ◽

2021 ◽

Vol 20 (2) ◽

Author(s):

Jason Lo ◽

Marina Mat Baki ◽

Yeoh Xing Yi ◽

Nik Hisyam Amirul ◽

Zahirrudin Zakaria

Keyword(s):

Potential Role ◽

Rare Complication ◽

Case Series ◽

Innominate Artery ◽

Survival Outcomes ◽

Permissive Hypotension ◽

Life Threatening ◽

History Of ◽

High Index Of Suspicion

Tracheo-innominate artery fistula (TIF) is a very rare complication related to tracheostomy and has been reported in 0.7% of patients, but certainly is one of the most life-threatening conditions. It is of paramount importance to maintain a high index of suspicion in evaluating patients with TIF and to anticipate occurrence of massive haemorrhage even during simple procedures related to tracheostomy such as tube change. We report 3 cases of TIF, each with a unique and unsuspecting history of the condition and review the emergency protocol in arresting the bleeding. We’ve also highlighted the potential role of permissive hypotension with sedation in improving survival outcomes of patients with TIF.

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A rare complication of cholecystolithiasis: perforation of the gallbladder

Journal of Ultrasonography ◽

10.15557/jou.2021.0009 ◽

2021 ◽

Vol 21 (84) ◽

pp. e63-e66

Author(s):

Bartosz Migda ◽

◽

Marlena Alicja Gabryelczak ◽

Anna Migda ◽

Katarzyna Prostacka ◽

...

Keyword(s):

Acute Pancreatitis ◽

Rare Complication ◽

Gallstone Ileus ◽

Mirizzi Syndrome ◽

The Other ◽

Gallbladder Perforation ◽

Appropriate Care ◽

History Of ◽

Complications Of Cholelithiasis ◽

Gallbladder Inflammation

Common complications of cholelithiasis include gallbladder inflammation, cholangitis, and acute pancreatitis. On the other hand, rare complications include gallbladder carcinoma, gallstone ileus, Mirizzi syndrome and gallbladder perforation. Some patients with cholecystitis do not require hospitalization. It is of key importance for proper further diagnosis and treatment to remember about the possible complications of cholecystitis, especially in oligosymptomatic patients. Therefore, ultrasound examinations in patients with a history of gallbladder stones should be performed with appropriate care. Ultrasound should be performed carefully in patients with a history of cholecystolithiasis, especially those oligosymptomatic, bearing in mind that there are some rare complications of this highly common clinical entity.

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SAT-579 Experiences with Hypertriglyceridemic Pancreatitis: A Mini Case Series

Journal of the Endocrine Society ◽

10.1210/jendso/bvaa046.345 ◽

2020 ◽

Vol 4 (Supplement_1) ◽

Author(s):

Priyanka Majety ◽

Richard D Siegel

Keyword(s):

Acute Pancreatitis ◽

Abdominal Pain ◽

Early Recognition ◽

Rare Complication ◽

Case Series ◽

Diagnostic Challenge ◽

Eruptive Xanthomas ◽

History Of ◽

Appropriate Therapy ◽

Pruritic Skin

Abstract Background: Hypertriglyceridemia (HTG) is a well-established cause of acute pancreatitis (AP) in up to 14% of all cases & up to 56% cases during pregnancy. The triad of HTG, Diabetic ketoacidosis (DKA) and AP is rarely seen posing diagnostic challenges. Early recognition of HTG-induced pancreatitis (HTGP) is important to provide appropriate therapy & prevent recurrence. In this case series, we discuss the diagnostic challenges and clinical features of HTGP. Clinical cases: Our first patient was a 65-year-old male with a history of hypertension who presented to the ER with abdominal pain and new-onset pruritic skin rash after a heavy meal. His exam and labs were notable for a diffuse papular rash on his back, triglycerides (TG) of 7073mg/dL (normal: <150mg/dL). The rash improved with the resolution of HTG. Our second patient was a 29-year-old male with a history of alcohol dependence who was found to have AP complicated by ARDS requiring intubation. Further testing revealed that his TG was 12,862mg/dL & his sodium (Na) was 102mEq/L. Although HTG was known to cause pseudohyponatremia, it was a diagnostic challenge to estimate the true Na level. In a third scenario, a 28-year-old female with a history of T2DM on Insulin presented with nausea & abdominal pain. Labs were suggestive of DKA and lipase was normal. CT abdomen showed changes consistent with AP. The TG level that was later added on was elevated to 4413mg/dL. She was treated with insulin that improved her TG level. Discussion: We present three cases of hypertriglyceridemic pancreatitis. While the presentation can be similar to other causes of acute pancreatitis (AP), there are factors in the diagnosis and management of HTGP that are important to understand. Occasionally, physical exam findings can be suggestive of underlying HTG. In the first scenario, our patient presented with eruptive xanthomas - a sudden eruption of crops of papules that can be pruritic. They are highly suggestive of HTG, often associated with serum TG levels > 1500mg/dL. Our second patient presented with pseudohyponatremia. HTG falsely lowers Na level, by affecting the percentage of water in plasma. Identifying this condition is important to prevent possible complications from aggressive treatment. This can be corrected either by using direct ion-specific electrodes or with the formula: Na change = TG * 0.002. DKA is associated with mild-moderate HTG in 30–50% cases. This is due to insulin deficiency causing activation of lipolysis in adipocytes & decreased activity of lipoprotein lipase (LPL). However, severe HTG is a rare complication of DKA, increasing the risk of AP. Diagnosis of AP in DKA poses many challenges: the common presenting complaint of abdominal pain, non-specific hyperlipasemia in DKA. AP with DKA has also been associated with normal lipase levels. A high clinical index of suspicion is required to diagnose HTGP in patients with DKA.

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Unmasking of Neurosarcoidosis

Journal of the Endocrine Society ◽

10.1210/jendso/bvab048.1260 ◽

2021 ◽

Vol 5 (Supplement_1) ◽

pp. A618-A618

Author(s):

Sharini Venugopal ◽

Binita Neupane ◽

Mahesh Nepal ◽

Luis F Chavez

Keyword(s):

Diabetes Insipidus ◽

Medical History ◽

Case Reports ◽

Rare Complication ◽

Case Series ◽

Primary Hypothyroidism ◽

Past Medical History ◽

Water Excretion ◽

History Of ◽

Glucocorticoid Deficiency

Abstract Introduction: Central diabetes insipidus is a rare complication of neurosarcoidosis. In patients with concomitant adrenal insufficiency (AI), the symptoms of Diabetes Insipidus (DI) can be masked. Case: A 55-year-old female with past medical history of sarcoidosis presented to the hospital with hematemesis, nausea and dizziness. She has a past medical history of cardiac sarcoidosis that was revealed on a PET scan done before 10 years for which she was being treated with methotrexate and prednisone. She was off prednisone for a year prior to hospitalization. She underwent an upper endoscopy that showed diffusely erythematous gastric mucosa in the antrum. She was also hypotensive on admission, and she received packed red blood transfusions after which her sodium increased from 145mmol/L to 165mmol/L (Normal: 135-145mmol/L) in 48 hours. Further workup revealed persistent hypernatremia and urine osmolality was 75mOsm/kg H2O. (Normal: 50-1200mOsm/kg H2O). She was also hypoglycemic and hypotensive requiring multiple fluid boluses throughout her hospitalization. This prompted us to perform a random cortisol that came back at 2.1ug/dl (Normal: 3-23ug/dl) and 1.8ug/dl on two occasions. Cortisol Stimulation test was subsequently ordered, but was done only at 30 minutes, and Cortisol increased from 1.8ug/dl to 6.3ug/dl. Free thyroxine was 0.5 ng/dl (Normal: 0.9-1.8 ng/dl) and her TSH was 7.58uIU/ml (Normal: 0.55-4.78uIU/ml). MRI of the brain revealed extensive areas of extra-axial supra-sellar/infundibular nodular homogeneous intense enhancement that is most consistent with neuro-sarcoid. She was started on prednisone 40 mg daily, Desmopressin 0.05 mg twice daily, and levothyroxine as well. Her sodium level normalized and was 137mmol/L at discharge. She followed up later with outpatient Endocrinology and reported around 90lbs weight gain and no more episodes of nausea or vomiting or epistaxis or lightheadedness. Conclusion: The involvement of the hypothalamic-pituitary axis in sarcoidosis is extremely rare and attributes to < 1% of patients with a sellar mass. Small case series have shown that hypogonadism is the most common endocrine abnormality followed by DI. Our patient had a long-standing history of sarcoidosis with her pituitary dysfunction unmasked only on admission for other causes. She did not manifest any symptoms of DI or AI. There have been case reports where the symptoms of DI are masked due to underlying glucocorticoid deficiency. There have been theories that glucocorticoid deficiency impairs renal water excretion by both ADH (Anti-diuretic hormone) dependent and ADH independent pathways. Another notable feature in our case is that our patient presented with primary hypothyroidism. In fact, sarcoidosis has been commonly implicated in auto-immune polyglandular syndromes type 3, which can present with auto-immune thyroiditis more so in females.

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Pneumomediastinum complicating COVID-19: a case series

European Journal of Medical Research ◽

10.1186/s40001-021-00585-9 ◽

2021 ◽

Vol 26 (1) ◽

Author(s):

Sérgio Henrique Bastos Damous ◽

Jones Pessoa dos Santos Junior ◽

Álvaro Vicente Alvarez Pezzano ◽

Mohamad Abdul Majid Chams ◽

Nathaly Haritov ◽

...

Keyword(s):

Rare Complication ◽

Ventilatory Support ◽

Case Series ◽

Pulmonary Involvement ◽

Orotracheal Intubation ◽

Case Presentation ◽

History Of ◽

Parenchymal Disease ◽

Relationship Of ◽

The Relationship

Abstract Background Pneumomediastinum is a rare complication of COVID-19 pneumonia, which may or may not be associated with invasive ventilatory support. Therefore, the report and findings associated with its evolution can be of great contribution in the management of this unknown disease. Case presentation Here, we present a series of four patients with severe pneumomediastinum requiring intensive care unit. These patients developed pneumomediastinum before or during orotracheal intubation (OTI) or without OTI. The four patients were three men and one woman with a mean age of 60.5 years (48–74 years). No patients had a known history of lung disease or traumatic events, except for one patient who had a history of smoking, but who was without parenchymal disease. All intubations were performed without complications. No cases of pneumomediastinum occurred after tracheostomy, and none of the patients had tomographic or bronchoscopic evidence of tracheal injury. Although the pneumomediastinum observed in our cases was apparently not related to a violation of the aerodigestive track, this complication was associated with a worse prognosis. Conclusion Pneumomediastinum is a rare complication of COVID-19 pneumonia, and the most likely etiopathogenesis is severe pulmonary involvement, which may or may not be associated with invasive ventilatory support. Future studies with a greater number of cases should elucidate the relationship of pneumomediastinum to a probable prognostic factor.

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Air in the urine: a mystified patient and a concerned surgeon

BMJ Case Reports ◽

10.1136/bcr-2018-227334 ◽

2019 ◽

Vol 12 (1) ◽

pp. bcr-2018-227334

Author(s):

Samarth Agarwal ◽

Ashish Sharma ◽

Ajay Aggarwal ◽

Satyanarayan Sankhwar

Keyword(s):

Acute Appendicitis ◽

Imaging Techniques ◽

Rare Complication ◽

Prior History ◽

Radiological Imaging ◽

Rare Type ◽

Detailed History ◽

History Of

Appendicovesical fistula is a rare type of enterovesical and a very rare complication of acute appendicitis. Herein, we report a case of a 22-year-old man who presented with cloudy urine and pneumaturia with a prior history of acute appendicitis. Imaging techniques including ultrasonography, CT and cystoscopy were performed to diagnose the abnormality. Diagnosis of this fistula is challenging and relies on detailed history and radiological imaging.

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1033. Thinking Outside the Bowel: Clostridium difficile Bacteremia Case Series

Open Forum Infectious Diseases ◽

10.1093/ofid/ofy210.870 ◽

2018 ◽

Vol 5 (suppl_1) ◽

pp. S308-S308 ◽

Cited By ~ 1

Author(s):

Adam Pettigrew ◽

Ripal Jariwala ◽

Kristen Zeitler ◽

Jose Montero ◽

Sandra Gompf ◽

...

Keyword(s):

Mortality Rate ◽

Clostridium Difficile ◽

Bloodstream Infection ◽

Broad Spectrum ◽

Case Series ◽

Prior History ◽

Broad Spectrum Antibiotics ◽

History Of ◽

Polymicrobial Bacteremia ◽

Hospital Acquired

Abstract Background While Clostridium difficile gastrointestinal infection (CDI) is the most common hospital-acquired infectious disease, C. difficile bacteremia (CDB) is exceedingly rare and its risk factors, mortality rate, and modalities of treatment are not well defined. Methods We conducted a retrospective, IRB approved, chart review of adult patients with a diagnosis of CDB admitted to our institutions from 2011 through 2017. Variables catalogued included previous antibiotic and proton pump inhibitor (PPI) use, co-morbid conditions, prior history of CDI, diarrhea at the time of CDB, active malignancy, and gastrointestinal (GI) disruption (e.g., perforated viscous, GI bleeding, abdominal malignancy). Treatment courses and outcomes for CDB were also gleaned. Results Seven patients with CDB were identified, with ages ranging from 35 to 81 years (median 65 years). Six (85.7%) patients had evidence of GI disruption and three (42.9%) were noted to have active cancer. Three (42.9%) patients had previous CDI by testing and three (42.9%) had complaints of diarrhea at the time of diagnosis. Six (85.7%) patients had exposure to PPIs before CDB diagnosis, and five (71.4%) had prior antibiotic exposure in the past 30 days. Five (71.4%) patients had a polymicrobial bloodstream infection, with the majority of organisms being enteric in nature. In terms of CDB treatment, the majority of patients received intravenous (IV) metronidazole and/or IV vancomycin in addition to broad-spectrum antibiotics due to the polymicrobial nature of their infection. Three (42.9%) patients died during their hospitalization, only one who had polymicrobial bacteremia. Conclusion CDI is the most common cause of hospital acquired infection, although rarely causes bacteremia. Notable findings in our population included older age, concomitant malignancy, evidence of GI disruption, and prior exposure to PPIs and antibiotics. Antibiotics chosen to treat CDB were IV metronidazole and/or IV vancomycin, with other broad-spectrum antibiotics utilized due to polymicrobial bacteremia. CDB is associated with a high mortality rate and is commonly manifested as a polymicrobial bloodstream infection. This is one of the larger case series that adds to the scant literature characterizing patients diagnosed with CDB. Disclosures All authors: No reported disclosures.

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Post-operative functional neurological symptom disorder after anesthesia

Bosnian Journal of Basic Medical Sciences ◽

10.17305/bjbms.2020.4646 ◽

2020 ◽

Author(s):

Ryan S D'Souza ◽

Matthew NP Vogt ◽

Edwin Rho

Keyword(s):

Neurological Symptom ◽

Past History ◽

Significant Proportion ◽

Case Series ◽

Pharmacologic Therapy ◽

Prior History ◽

General Anesthetic ◽

Tertiary Referral Hospital ◽

History Of ◽

Functional Neurological Symptom Disorder

A rare manifestation during the post-anesthetic period may include the occurrence of functional neurological symptom disorder (FNSD). FNSD is described as neurological symptoms that are not consistently explained by neurological or medical conditions. We report a case series consisting of six patients who underwent a general anesthetic at a tertiary referral hospital and experienced FNSD in the immediate post-anesthetic period. Life-threatening causes were excluded based on benign physical exam findings and knowledge of past history. Five of six cases manifested with FNSD only in the immediate post-operative setting after exposure to anesthesia, and never otherwise experienced these symptoms during their normal daily lives. MEDLINE and Google Scholar were searched through October 2019 using a highly-sensitive search strategy and identified 38 published cases of post-anesthetic FNSD. Meta-analysis of pooled clinical data revealed that a significant proportion of patients were females (86%), reported a history of psychiatric illness (49%), reported a prior history of FNSD (53%), and underwent general anesthesia as the primary anesthetic (93%). The majority of patients were exposed to diagnostic studies (66% received radiographic tests and 52% received electroencephalogram) as well as pharmacologic therapy (57%). While no deaths occurred, many patients had unanticipated admission to the hospital (53%) or to the intensive care unit (25%). These data may help inform the anesthesia literature on presentation, risk factors, and treatment outcomes of FNSD in the context of anesthetic administration. We contemplate whether anesthetic agents may predispose a vulnerable brain to manifest with involuntary motor and sensory control seen in FNSD.

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The Novel Use of Flexible Endoscopic Techniques in the Management of Pharyngocutaneous Fistulas

Digestive Disease Interventions ◽

10.1055/s-0041-1735319 ◽

2021 ◽

Author(s):

Shivam Patel ◽

Colin G. DeLong ◽

Luis De Jesus Sanchez ◽

Neerav Goyal ◽

Eric M. Pauli

Keyword(s):

Case Series ◽

Spontaneous Resolution ◽

Prior History ◽

Pharyngocutaneous Fistula ◽

The Novel ◽

Endoscopic Techniques ◽

Anterolateral Thigh ◽

Successful Resolution ◽

History Of ◽

Reduced Rate

AbstractPharyngocutaneous fistula (PCF) is a complication of laryngectomies in 14 to 23% of patients. The rate of spontaneous resolution of small and low-output fistulas has been shown to be 65 to 94% in those who are radiation-naive, with a reduced rate of resolution in patients who were previously radiated as low as 33%. Two patients are presented who underwent total laryngopharyngectomy and anterolateral thigh free flap reconstruction at our institution eventually complicated with PCF. All the pertinent patient data were retrieved through chart review from the records of our institution. The cases presented had a prior history of radiation or chemoradiation complicating the spontaneous resolution of the PCF. Both patients had successful resolution of PCF with the flexible endoscopic techniques presented. This case series highlights the management of small PCFs using flexible endoscopic techniques including over-the-scope clips and Vicryl mesh plugs.

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