Uncommon Causes of Acute Abdominal Pain – A Pictorial Essay

Acute abdomen is one of the most common clinical conditions requiring a radiological investigation. Ultrasound is the primary modality of choice which can diagnose some of the common causes of acute abdomen. However, sometimes the underlying cause for the pain is far more complicated than expected mandating a high degree of suspicion to suggest further investigation with contrast enhanced computed tomography or magnetic resonance imaging. Here, we have compiled a comprehensive series of selected cases to highlight the conditions which can be easily overlooked unless carefully sought for. This article also emphasizes the importance of multimodality approach to arrive at the final diagnosis with an increased overall diagnostic accuracy which in turn improves patient management and prognosis.

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Acute Abdomen due to Mutual Tangle of Two Small Paratubal Cysts

Case Reports in Obstetrics and Gynecology ◽

10.1155/2018/2351809 ◽

2018 ◽

Vol 2018 ◽

pp. 1-4

Author(s):

Hiroharu Kobayashi ◽

Shinichi Shibuya ◽

Kentaro Iga ◽

Keiichiro Kato ◽

Airi Kato ◽

...

Keyword(s):

Acute Abdomen ◽

Histopathological Examination ◽

Lower Abdominal Pain ◽

Cystic Teratoma ◽

Cystic Mass ◽

Mature Cystic Teratoma ◽

Contrast Enhanced ◽

The Right ◽

Enhanced Computed Tomography ◽

Paratubal Cyst

A 30-year-old woman (gravida 0) visited our hospital with a complaint of right lower abdominal pain. Transvaginal ultrasonography revealed a 5-cm swollen right ovary, which was suspected to be a mature cystic teratoma. Pelvic examination revealed moderate pain. Contrast-enhanced computed tomography showed a 44-mm cystic mass containing fat and calcified material in the right pelvis. Since torsion was suspected, emergent laparoscopic surgery was performed. Intraoperative findings were a swollen right ovary without torsion or congestion. Two small pedunculated 1- and 2-cm diameter paratubal cysts that grew from almost the same place of the ampulla of the right fallopian tube were observed. The thin stalk of the 1-cm paratubal cyst was entangled around the stalk of the 2-cm paratubal cyst, with its head congested. Through a small abdominal laparoscopic incision, the tumor of the right ovary and the two paratubal cysts were excised. Histopathological examination revealed that the right ovarian tumor was a mature cystic teratoma, and the two paratubal cysts had no malignancy. This case showed that only a 2-cm tumor with congestion caused the acute abdomen.

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Intraperitoneal hemorrhage after cupping therapy

Hong Kong Journal of Emergency Medicine ◽

10.1177/1024907918784076 ◽

2018 ◽

Vol 27 (2) ◽

pp. 107-109

Author(s):

Meng-Chuan Lu ◽

Chih-Jen Yang ◽

Shih-Hung Tsai ◽

Chih-Chieh Hung ◽

Sy-Jou Chen

Keyword(s):

Rare Complication ◽

Hypovolemic Shock ◽

Cupping Therapy ◽

Tissue Ischemia ◽

Intraperitoneal Hemorrhage ◽

Relieve Pain ◽

History Of ◽

Enhanced Computed Tomography ◽

Clinical Conditions ◽

High Degree

Introduction: Cupping therapy has been widely performed in oriental countries and considered a safety alternative to relieve pain. Here, we report a rare complication from abdominal cupping. Case presentation: A 49-year-old man presented with a 2-day history of left upper quadrant abdominal pain after cupping therapy 3 days earlier. His abdomen was soft but appeared a localized rebounding tenderness. Contrast-enhanced computed tomography of the abdomen showed intraperitoneal hemorrhage originated from the left upper quadrant of the omentum. Discussion: Several mechanisms are proposed for the development of intraperitoneal hemorrhage after cupping therapy, including the tensile stress generated by cupping that facilitates the disruption of omentum vessels, strong negative pressure generated by cupping that suppresses blood supply to the cup-applied sites causing adjacent tissue ischemia, and subsequent vascular extravasation. Treatment for intraperitoneal hemorrhage depends on clinical conditions. Stable patients can be managed conservatively, whereas surgery is reserved for those with continuous bleeding and hypovolemic shock. Conclusion: Cupping therapy complicated with omentum bleeding can present insidiously until peritoneal irritation developed by intraperitoneal hemorrhage. A comprehensive history taking and a high degree of vigilance are crucial to diagnose early patients with this rare complication.

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Mixed cortico-medullary adrenal carcinoma in children: looks are deceptive!!

Annals of Pediatric Surgery ◽

10.1186/s43159-021-00134-3 ◽

2021 ◽

Vol 17 (1) ◽

Author(s):

Arti Khatri ◽

Nidhi Mahajan ◽

Niyaz Ahmed Khan ◽

Natasha Gupta

Keyword(s):

Past History ◽

Case Reports ◽

Final Diagnosis ◽

Adrenal Carcinoma ◽

Case Presentation ◽

First Case ◽

Contrast Enhanced ◽

Paediatric Age ◽

History Of ◽

Enhanced Computed Tomography

Abstract Background Mixed cortico-medullary adrenal carcinoma (MCMAC) is an extremely rare entity with scarce literature on its cytomorphology. Case presentation A 2-year-old girl presented with abdominal pain for 3 days and a past history of fever with significant weight loss. On examination, a non-tender left hypochondrial firm mass and an enlarged left supraclavicular node were found. Twenty-four-hour urinary levels of VMA were marginally high. Contrast-enhanced computed tomography of the abdomen showed a suprarenal heterogeneous mass encasing major vessels. Aspiration cytology of both mass and node showed similar features comprising a predominant population of singly scattered large cells with moderate cytoplasm, eccentric nucleus and prominent nucleolus in a necrotic background. Tumour cells expressed Synaptophysin and Melan-A. In view of increasing respiratory distress, debulking surgery was performed, and histopathology of the specimen revealed the presence of both malignant medullary and cortical components supported by immunohistochemistry making a final diagnosis of MCMAC. The patient succumbed to death in the postoperative period. The cytology slides were reviewed and were seen to show a dual cell population. Conclusion Coexistent malignant cortical and medullary tumour of the adrenal gland is the first case reported in the paediatric age group in the literature with only three previous case reports in adults.

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Retroperitoneal paraganglioma: a chameleon masquerading as an adrenal pheochromocytoma

Annals of The Royal College of Surgeons of England ◽

10.1308/rcsann.2018.0193 ◽

2019 ◽

Vol 101 (2) ◽

pp. e62-e65 ◽

Cited By ~ 2

Author(s):

K Parmar ◽

A Chandna ◽

S Kumar

Keyword(s):

Vena Cava ◽

Final Diagnosis ◽

Contrast Enhanced ◽

Rare Tumours ◽

Close Proximity ◽

Adrenal Pheochromocytoma ◽

Suprarenal Mass ◽

One Year ◽

Enhanced Computed Tomography ◽

Contrast Enhanced Computed Tomography

Retroperitoneal paragangliomas are rare tumours arising from neural crest cells located near or in the autonomic nervous system; right from the skull bass to the pelvic floor. Often called the great masqueraders, their diagnosis and treatment is often difficult and fraught with danger, considering the close proximity of these tumours to important retroperitoneal organs. A 29-year-old woman presented to the outpatient department with complaints of paroxysms of headache, sweating and palpitations for one year. She was found to have elevated urinary metadrenalines (metanephrines) and a suprarenal mass on contrast-enhanced computed tomography of the abdomen, which demonstrated increased tracer activity on I-131 iodine-123 meta-iodobenzylguanidine scintigraphy. Adrenal pheochromocytoma was diagnosed and she underwent laparoscopic adrenalectomy after stabilisation of her blood pressure. Laparoscopy revealed a large suprarenal mass with dense adhesions to the inferior vena cava that was carefully separated from the vein and surrounding structures. The cut section revealed a heterogeneous mass encasing a normal adrenal gland and histopathology confirmed the same, confirming the final diagnosis of retroperitoneal paraganglioma.

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Specific Radiological Findings of Traumatic Gastrointestinal Tract Injuries in Patients with Blunt Chest and Abdominal Trauma

Canadian Association of Radiologists Journal ◽

10.1016/j.carj.2014.11.003 ◽

2015 ◽

Vol 66 (2) ◽

pp. 158-163 ◽

Cited By ~ 6

Author(s):

Nima Kokabi ◽

Elie Harmouche ◽

Minzhi Xing ◽

Waqas Shuaib ◽

Pardeep K. Mittal ◽

...

Keyword(s):

Computed Tomography ◽

Abdominal Trauma ◽

Early Recognition ◽

Radiological Findings ◽

Hollow Viscus ◽

Contrast Enhanced ◽

Hollow Viscus Injury ◽

Pictorial Essay ◽

Enhanced Computed Tomography ◽

Contrast Enhanced Computed Tomography

Gastrointestinal hollow viscus injury after blunt chest and abdominal trauma is uncommon and complicates 0.6%-1.2% of all cases of trauma. Early recognition of such injuries significantly decreases morbidity and mortality. Since physical examination is not accurate in detecting such injuries, contrast-enhanced computed tomography has been the mainstay for diagnosis in many emergency departments. This pictorial essay aims to review the incidence, mechanisms, and signs of gastrointestinal hollow viscus injuries in the setting of blunt chest and abdominal trauma.

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Diagnostic evaluation of congenital respiratory stridor in children

New Medicine ◽

10.25121/newmed.2019.23.1.3 ◽

2019 ◽

Vol 23 (1) ◽

Author(s):

Monika Jabłońska-Jesionowska ◽

Lidia Zawadzka-Głos

Keyword(s):

Respiratory Tract ◽

General Anaesthesia ◽

Lower Respiratory Tract ◽

Final Diagnosis ◽

Diagnostic Evaluation ◽

Radiographic Examination ◽

Common Cause ◽

Contrast Enhanced ◽

The Right ◽

Enhanced Computed Tomography

Introduction. Congenital respiratory stridor in children is the result of respiratory tract pathology located at various anatomical levels. There is an ongoing debate on whether every case of stridor requires diagnostic evaluation and which method is the most effective for determining the final diagnosis. Aim. The aim of the present study is to answer the question which procedure should be performed to diagnose the casuse of congenital stridor in children and why, and what the most common cause of the stridor is. Material and methods. A group of 110 children examined due to congenital respiratory stridor was analysed. The children’s general condition was assessed and imaging studies and lower respiratory tract endoscopy were performed under general anaesthesia. In some children cardiac ultrasound and contrast-enhanced radiographic examination of the oesophagus or contrast-enhanced computed tomography scan of the chest were performed. Results. Children aged 3 days to 11 years were analysed. The most common cause of stridor was congenital laryngeal hypotonia found in 50% of children and the second most common was abnormalities of the great arteries in 28% of children. Biphasic stridor, which may be a sign of multiple respiratory abnormalities, was diagnosed most frequently. It was only lower respiratory tract endoscopy performed under general anaesthesia that made it possible to make the right diagnosis. Conclusions. The most useful diagnostic method for congenital respiratory stridor is lower respiratory tract endoscopy under general anaesthesia, which is used to evaluate both the larynx and the trachea since defects may coexist at various respiratory levels. It is also for this reason that the type of stridor is not tantamount to the level at which the pathology is located in the respiratory tract. One needs to bear in mind that abnormalities of the great arteries may also be the cause of congenital respiratory stridor.

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A rare oesophageal inflammatory myofibroblastic tumour treated by endoscopy

Annals of The Royal College of Surgeons of England ◽

10.1308/rcsann.2017.0113 ◽

2018 ◽

Vol 100 (4) ◽

pp. e66-e68

Author(s):

ZY Fang ◽

HX Huang ◽

C Lu ◽

XX Zhou ◽

F Ji ◽

...

Keyword(s):

Computed Tomography ◽

Final Diagnosis ◽

Pathological Examination ◽

Inflammatory Myofibroblastic Tumour ◽

Poor Appetite ◽

Contrast Enhanced ◽

Mesenchymal Neoplasm ◽

Oesophageal Tumour ◽

Enhanced Computed Tomography ◽

Contrast Enhanced Computed Tomography

An inflammatory myofibroblastic tumour is a mesenchymal neoplasm that mostly involves the lung and rarely involves the oesophagus. Surgery has been most commonly used for the treatment of oesophageal inflammatory myofibroblastic tumours but there are no definite guidelines for their diagnosis and treatment. We describe the case of a 60-year-old woman presenting with dysphagia and poor appetite who was diagnosed with a submucosal oesophageal tumour by contrast enhanced computed tomography and ultrasonography endoscopy. She was treated successfully by endoscopic submucosal dissection with no complications. The final diagnosis was confirmed by pathological examination.

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Transfusion-Dependent Anemia in a Simultaneous Pancreas and Kidney Transplant Recipient

Case Reports in Transplantation ◽

10.1155/2020/2841456 ◽

2020 ◽

Vol 2020 ◽

pp. 1-4

Author(s):

Jeevan Prakash Gopal ◽

David Taube ◽

John Martin ◽

Simona Deplano ◽

Saral Desai ◽

...

Keyword(s):

Computed Tomography ◽

Transplant Recipient ◽

Gastrointestinal Bleeding ◽

Kidney Transplant Recipient ◽

Final Diagnosis ◽

Contrast Enhanced ◽

Computed Tomography Scans ◽

Diagnostic Difficulties ◽

Enhanced Computed Tomography ◽

Contrast Enhanced Computed Tomography

A case of transfusion-dependent anemia in a simultaneous pancreas and kidney (SPK) transplant recipient that masqueraded as gastrointestinal bleeding (GIB) is described. The anemia was attributed to bleeding from the donor duodenal cuff based on balloon enteroscopy findings. The patient underwent multiple contrast-enhanced computed tomography scans and multiple endoscopies with confounding features until, eventually, the diagnosis was established. We discuss the diagnostic difficulties and the therapeutic dilemma, along with the pitfalls in ascertaining the final diagnosis.

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Synchronous Renal Dedifferentiated Liposarcoma and Retroperitoneal Well-Differentiated Liposarcoma: A Case Report With Literature Review

International Journal of Surgical Pathology ◽

10.1177/1066896920981682 ◽

2020 ◽

pp. 106689692098168

Author(s):

Ling Nie ◽

Xueqin Chen ◽

Jing Gong ◽

Mengni Zhang ◽

Miao Xu ◽

...

Keyword(s):

Left Kidney ◽

Final Diagnosis ◽

Dedifferentiated Liposarcoma ◽

Pathological Examination ◽

Retroperitoneal Mass ◽

Mdm2 Gene ◽

Contrast Enhanced ◽

High Grade Sarcoma ◽

Well Differentiated ◽

Enhanced Computed Tomography

Liposarcoma is the most common soft tissue malignancy and usually occurs in the retroperitoneum or the extremities but rarely in the kidney. In this article, we report a case of a 71-year-old female patient who presented with abdominal lump and left flank pain for 1 month. An abdominal contrast-enhanced computed tomography scan demonstrated a 12 cm × 7 cm solid mass arising from the upper pole of left kidney and another 8 cm × 6 cm low-density retroperitoneal mass with fat density. Radical nephrectomy of the left kidney and resection of the retroperitoneal mass were performed. Surprisingly, pathological examination revealed a high-grade sarcoma (with minor lipomatous component) in the left kidney and a retroperitoneal well-differentiated liposarcoma. MDM2 gene amplification was identified by fluorescence in situ hybridization in both tumors, supporting final diagnosis of dedifferentiated liposarcoma of the kidney and well-differentiated liposarcoma of the retroperitoneum.

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