Whirlpool No More: A Case of Misdiagnosed Malrotation with Midgut Volvulus

Introduction: Adult intestinal malrotation with midgut volvulus is rare and most often diagnosed on abdominal imaging. Once the diagnosis is made, prompt surgical intervention is necessary. A finding suggestive of malrotation with midgut volvulus on abdominal imaging is the “whirlpool” sign where the superior mesenteric vein and superior mesenteric artery twist at the root of the abdominal mesentery. This sign was once thought to be pathognomonic, but recent studies have shown that it can be seen in asymptomatic patients. Case Report: A 20-year-old female presented to our emergency department with diffuse abdominal pain. Computed tomography demonstrated the “whirlpool” sign with a concern for malrotation with midgut volvulus. Surgical consultation was obtained and the patient was rushed to the operating room for an exploratory laparotomy. Normal mesenteric attachments were seen and no significant pathology was identified during the laparotomy. The patient was eventually diagnosed with gastritis and discharged in stable condition. Conclusion: Emergency physicians and surgeons alike should be cautious in confirming malrotation with midgut volvulus solely due to the “whirlpool” sign on abdominal imaging. Premature diagnostic closure can lead to unnecessary procedures and interventions for patients as in the case we report here.

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Clinical outcomes and prognostic factors for cavernous hemangiomas of the spinal cord: a retrospective cohort study

Journal of Neurosurgery Spine ◽

10.3171/2019.1.spine18854 ◽

2019 ◽

Vol 31 (2) ◽

pp. 271-278 ◽

Cited By ~ 3

Author(s):

Narihito Nagoshi ◽

Osahiko Tsuji ◽

Daisuke Nakashima ◽

Ayano Takeuchi ◽

Kaori Kameyama ◽

...

Keyword(s):

Conservative Treatment ◽

Surgical Intervention ◽

Lesion Size ◽

Sudden Onset ◽

Neurological Function ◽

Neurological Injury ◽

Prognostic Indicators ◽

Asymptomatic Patients ◽

Surgical Data ◽

Unstable Gait

OBJECTIVEIntramedullary cavernous hemangioma (CH) is a rare vascular lesion that is mainly characterized by the sudden onset of hemorrhage in young, asymptomatic patients, who then experience serious neurological deterioration. Despite the severity of this condition, the therapeutic approach and timing of intervention for CH remain matters of debate. The aim of this study was to evaluate the clinical characteristics of CH patients before and after surgery and to identify prognostic indicators that affect neurological function in these patients.METHODSThis single-center retrospective study included 66 patients who were treated for intramedullary CH. Among them, 57 underwent surgery and 9 patients received conservative treatment. The authors collected demographic, symptomology, imaging, neurological, and surgical data. Univariate and multivariate logistic regression analyses were performed to identify the prognostic indicators for neurological function.RESULTSWhen comparing patients with stable and unstable gait prior to surgery, patients with unstable gait had a higher frequency of hemorrhagic episodes (52.4% vs 19.4%, p = 0.010), as assessed by the modified McCormick Scale. The lesion was significantly smaller in patients who underwent conservative treatment compared with surgery (2.5 ± 1.5 mm vs 5.9 ± 4.1 mm, respectively; p = 0.024). Overall, the patients experienced significant neurological recovery after surgery, but a worse preoperative neurological status was identified as an indicator affecting surgical outcomes by multivariate analysis (OR 10.77, 95% CI 2.88–40.36, p < 0.001). In addition, a larger lesion size was significantly associated with poor functional recovery in patients who had an unstable gait prior to surgery (8.6 ± 4.5 mm vs 3.5 ± 1.6 mm, p = 0.011).CONCLUSIONSOnce a hemorrhage occurs, surgical intervention should be considered to avoid recurrence of the bleeding and further neurological injury. In contrast, if the patients with larger lesion presented with worse preoperative functional status, surgical intervention could have a risk for aggravating the functional deficiencies by damaging the thinning cord parenchyma. Conservative treatment may be selected if the lesion is small, but regular neurological examination by MRI is needed for assessment of a change in lesion size and for detection of functional deterioration.

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Emergency Surgery during COVID-19: Lessons Learned

The Surgery Journal ◽

10.1055/s-0040-1716335 ◽

2020 ◽

Vol 06 (03) ◽

pp. e167-e170

Author(s):

Hemanga K. Bhattacharjee ◽

Shafneed Chaliyadan ◽

Eshan Verma ◽

Keerthi Kumaran ◽

Priyank Bhargava ◽

...

Keyword(s):

Stable Condition ◽

Exploratory Laparotomy ◽

Sigmoid Volvulus ◽

Lessons Learned ◽

Suspected Case ◽

Surgical Emergencies ◽

Viral Particles ◽

Hospital Patients ◽

Perforation Peritonitis ◽

Precautionary Measures

Abstract Introduction The ongoing coronavirus disease-2019 (COVID-19) pandemic has disrupted health services throughout the world. It has brought in several new challenges to deal with surgical emergencies. Herein, we report two suspected cases of COVID-19 that were operated during this “lockdown” period and highlight the protocols we followed and lessons we learned from this situation. Result Two patients from “red zones” for COVID-19 pandemic presented with acute abdomen, one a 64-year male, who presented with perforation peritonitis and another, a 57-year male with acute intestinal obstruction due to sigmoid volvulus. They also had associated COVID-19 symptoms. COVID-19 test could not be done at the time of their presentation to the hospital. Patients underwent emergency exploratory laparotomy assuming them to be positive for the infection. Surgical team was donned with full coverall personal protective equipment. Sudden and uncontrolled egression intraperitoneal free gas was avoided, Echelon flex 60 staplers were used to resect the volvulus without allowing the gas from the volvulus to escape; mesocolon was divided using vascular reload of the stapler, no electrosurgical devices were used to avoid the aerosolization of viral particles. Colostomy was done in both the patients. Both the patients turned out to be negative for COVID-19 subsequently and discharged from hospital in stable condition. Conclusion Surgeons need to adapt to safely execute emergency surgical procedures during this period of COVID-19 pandemic. Preparedness is of paramount importance. Full precautionary measures should be taken when dealing with any suspected case.

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Small Bowel Obstruction Induced by Concurrent Postoperative Intra-Abdominal Adhesions and Small Bowel Fecal Materials in a Young Dog

Veterinary Sciences ◽

10.3390/vetsci8050083 ◽

2021 ◽

Vol 8 (5) ◽

pp. 83

Author(s):

Jae-Eun Hyun ◽

Hyun-Jung Han

Keyword(s):

Small Bowel ◽

Small Bowel Obstruction ◽

Bowel Obstruction ◽

Surgical Intervention ◽

Gastrointestinal Symptoms ◽

Exploratory Laparotomy ◽

Abdominal Adhesions ◽

Abdominal Radiography ◽

Foreign Body Removal ◽

Small Intestinal

A 7-month-old neutered male poodle dog presented with general deterioration and gastrointestinal symptoms after two separate operations: a jejunotomy for small-intestinal foreign body removal and an exploratory laparotomy for diagnosis and treatment of the gastrointestinal symptoms that occurred 1 month after the first surgery. The dog was diagnosed as having small-bowel obstruction (SBO) due to intra-abdominal adhesions and small-bowel fecal material (SBFM) by using abdominal radiography, ultrasonography, computed tomography, and laparotomy. We removed the obstructive adhesive lesion and SBFM through enterotomies and applied an autologous peritoneal graft to the released jejunum to prevent re-adhesion. After the surgical intervention, the dog recovered quickly and was healthy at 1 year after the surgery without gastrointestinal signs. To our knowledge, this study is the first report of a successful treatment of SBO induced by postoperative intra-abdominal adhesions and SBFM after laparotomies in a dog.

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An unusual case of pediatric abdominal pain

CJEM ◽

10.2310/8000.2011.110163 ◽

2011 ◽

Vol 13 (02) ◽

pp. 133-138 ◽

Cited By ~ 3

Author(s):

Lars P. Bjoernsen ◽

M. Bruce Lindsay

Keyword(s):

Abdominal Pain ◽

Colonic Obstruction ◽

Exploratory Laparotomy ◽

Symptomatic Treatment ◽

Systematic Evaluation ◽

White Female ◽

Symptomatic Therapy ◽

Regional Lymph Nodes ◽

Diffuse Abdominal Pain ◽

Gastrografin Enema

ABSTRACTChronic and recurrent abdominal pains are common complaints in children and adolescents, but the evaluation in the emergency department (ED) can be challenging. We present a rare yet serious case of a 17-year-old white female who presented to the ED with a 2-day history of diffuse abdominal pain, nausea, and intractable vomiting. Abdominal examination and imaging, including computed tomography (CT), were negative during an episode 6 weeks previously. This was her fifth similar episode in a 2-month period, and she had been seen at three different hospitals and admitted on each occasion. Three days prior to presentation to our ED, she was seen at a gastroenterology clinic and diagnosed with irritable bowel syndrome and an ovarian cyst. Symptomatic therapy during the current presentation, with intravenous fluids, antiemetics, and parenteral narcotics, failed to alleviate her abdominal pain and vomiting. Emergent CT evaluation revealed a high-grade colonic obstruction with focal circumferential narrowing in the transverse colon and a lower gastrointestinal follow-through radiograph with Gastrografin enema showed a classic “apple-core” lesion. Colonic adenocarcinoma with positive regional lymph nodes was found during emergent exploratory laparotomy. Pediatric patients with recurrent, episodic abdominal pain should undergo systematic evaluation and symptomatic treatment. A previous negative workup should not dissuade emergency physicians from proceeding with a systematic and thorough evaluation of the pediatric patient presenting with abdominal pain and vomiting.

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A study on postnatal evaluation and follow-up of infants with antenatally detected hydronephrosis

International Journal of Contemporary Pediatrics ◽

10.18203/2349-3291.ijcp20173716 ◽

2017 ◽

Vol 4 (5) ◽

pp. 1677

Author(s):

Soundaiyan Balasankar ◽

Jeyaraman Balasubramanian

Keyword(s):

Urinary Tract ◽

Surgical Intervention ◽

P Value ◽

Postnatal Life ◽

Antenatal Hydronephrosis ◽

Urinary Tract Anomaly ◽

Antenatal Ultrasonography ◽

Significant Pathology ◽

Anteroposterior Renal Pelvic Diameter

Background: Antenatal hydronephrosis(ANH) has now become a frequent diagnosis with the increasing use of antenatal ultrasonography. Objective of present study was to evaluate and follow up infants with antenatally detected hydronephrosis and to determine whether there is significant correlation between anteroposterior renal pelvic diameter detected in antenatal USG and urinary tract anomalies detected postnatally.Methods: After obtaining an informed consent, all neonates with antenatal ultrasound showing hydronephrosis (n=80) were enrolled in the study. Postnatal ultrasound was done at 3 days ,1 month and 6 months of postnatal life. Atleast 6 months followup was done to look for spontaneous resolution or other significant pathology. Micturating cystourethrography/radionuclide scan done in selected cases.Results: Out of 80 cases ,43 had mild,24 had moderate and 13 had severe degrees of hydronephrosis.31 of them (9 mild,10 moderate and 12 with severe hydronephrosis) had postnatal anomaly detected.14 of them (1 mild, 4 moderate and 9 with severe hydronephrosis) underwent surgery. As the grade of antenatal hydronephrosis increases from mild, moderate to severe, the relative risk of postnatal anomaly and requirement of surgical intervention also increased (p value<0.0001).Conclusions: Antenatal hydronephrosis may be associated with significant postnatal urinary tract anomaly with risk quantified by the measurement of anteroposterior renal pelvic diameter(APPD).

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Mysterious Gelly Belly: a Case Report of Pseudomyxoma Peritonei and Literature Review

Journal of Gastroenterology & Digestive Systems ◽

10.33140/jgds.04.02.02 ◽

2020 ◽

Vol 4 (2) ◽

Keyword(s):

Abdominal Pain ◽

Case Report ◽

Literature Review ◽

Pseudomyxoma Peritonei ◽

Clinical Condition ◽

Imaging Techniques ◽

Abdominal Distension ◽

Exploratory Laparotomy ◽

Primary Site ◽

Diffuse Abdominal Pain

Pseudomyxoma peritonei (PMP) is a rare clinical condition defined as extensive intraperitoneal spread of mucus associated with a variety of mucinous tumors. Although appendix has usually been implicated as the primary site, some reports found no cause. This case also describes a PMP with no identifiable primary site. A 52-year-old male presented with an abdominal distension evolving for 3 months associated with diffuse abdominal pain, imaging techniques objective intra peritoneal mucoid materials with septated ascites but it failed to identify the primary site. Exploratory laparotomy with Biopsy confirmed PMP but also failed to found the original site.

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Duplication cyst with midgut volvulus in a neonate: an unusual presentation

BMJ Case Reports ◽

10.1136/bcr-2020-235526 ◽

2020 ◽

Vol 13 (8) ◽

pp. e235526

Author(s):

Nitin G Pai ◽

Santosh Prabhu ◽

Pavithra Prabhakar ◽

Vijay Kumar

Keyword(s):

Surgical Intervention ◽

Case Reports ◽

Anorectal Malformations ◽

Duplication Cyst ◽

Midgut Volvulus ◽

Rare Association ◽

Internal Hernias ◽

Gastrointestinal Duplication Cyst ◽

Resection And Anastomosis ◽

Gastrointestinal Duplication

Incomplete intestinal fixation or malrotation of gut with midgut volvulus is one of the important causes of bilious vomiting in neonates. The incidence of malrotation of gut in population is 4% and that of duplication cyst is 1:4500. Patients with malrotation are prone to develop midgut volvulus due to their narrow mesenteric base demanding urgent surgical intervention. Common associated anomalies are intrinsic duodenal obstruction, internal hernias, caecal volvulus, anorectal malformations and Hirschsprung’s disease. The present case refers to a 4-day-old neonate who presented with malrotation of gut with reverse volvulus and an associated gastrointestinal duplication cyst, which is a rare association with only few reported case reports. After imaging with ultrasound and contrast radiograph, the baby underwent prompt surgical intervention in the form of Ladd’s procedure with resection and anastomosis of jejunal duplication cyst.

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Midgut Volvulus With Whirlpool Sign

Clinical Gastroenterology and Hepatology ◽

10.1016/j.cgh.2015.06.003 ◽

2016 ◽

Vol 14 (2) ◽

pp. e13 ◽

Cited By ~ 2

Author(s):

Pankaj Kumar Shrimal ◽

D. Nageshwar Reddy ◽

Jagadeesh Rampal Singh

Keyword(s):

Midgut Volvulus ◽

Whirlpool Sign

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Jejunal Intussusception: A Rare Presentation of Carcinoid Tumor

Case Reports in Surgery ◽

10.1155/2015/260697 ◽

2015 ◽

Vol 2015 ◽

pp. 1-3 ◽

Cited By ~ 1

Author(s):

Umashankkar Kannan ◽

Amir A. Rahnemai-Azar ◽

Ashish N. Patel ◽

Vinaya Gaduputi ◽

Ajay K. Shah

Keyword(s):

Primary Anastomosis ◽

Exploratory Laparotomy ◽

Sudden Onset ◽

Pathological Examination ◽

Rare Presentation ◽

Metastatic Carcinoid ◽

Diffuse Abdominal Pain ◽

Well Differentiated ◽

Small Bowel Segment ◽

Distal Jejunum

A 55-year-old male presented to the emergency department with sudden onset of diffuse abdominal pain for one day. Physical examination was remarkable for tenderness in the umbilical region. A CT scan of the abdomen showed intussusception involving the jejunum without any mass. The patient then underwent an exploratory laparotomy. During surgery, the distal jejunum was intussuscepted with mesenteric lymphadenopathy. Liver showed nodular deposits in both lobes of the liver. The involved small bowel segment was resected with primary anastomosis and liver was biopsied. Pathological examination showed multifocal deposits of well-differentiated carcinoids in the jejunum. The liver and mesenteric deposits were positive for metastatic carcinoid. Patient recovered well without any complications.

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The efficacy of a shared-care surveillance protocol for asymptomatic renal calculi

Journal of Clinical Urology ◽

10.1177/2051415816686780 ◽

2017 ◽

Vol 10 (4) ◽

pp. 368-373

Author(s):

P Ravindra ◽

J Voss ◽

S Hall ◽

RJ Stanford ◽

SD Scriven ◽

...

Keyword(s):

Surgical Intervention ◽

Cost Effective ◽

Renal Calculi ◽

Shared Care ◽

X Ray ◽

Referral Criteria ◽

Care Protocol ◽

Asymptomatic Patients ◽

Effective Manner

Objective: Patients at our institution with asymptomatic calyceal stones (<11 mm) are discharged to their GPs with a request for 12- and 24-month X-ray KUBs with specific re-referral criteria. We aimed to assess the effectiveness of this shared care protocol as well as to investigate long-term outcomes. Patients and methods: All patients satisfying the above criteria discharged during October 2009–June 2011 were reviewed for protocol compliance, symptomatic events and/or surgical intervention up to July 2015. Results: A total of 134 patients were identified. Out of 115 patients eligible for their first X-ray, and 100 patients eligible for their second X-ray, 43% and 26% respectively were performed. Of these, 75% demonstrated no progression. No patients were treated surgically solely on the basis of radiographic progression. Over a mean five-year follow-up, patients had a 39% chance of experiencing a symptomatic event and a 24% chance of requiring surgical intervention (ESWL, ureteroscopy and/or PCNL). Risk factors included a previous stone history and having a total stone size >10 mm. Conclusion: There was poor adherence to this protocol. Despite this, only symptomatic patients were treated surgically, challenging the value of indefinite surveillance of asymptomatic patients. Longitudinal studies are needed to determine a cost-effective manner in which these patients can be safely followed up.

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