Acute Diffuse Peritonitis Due to Spontaneous Rupture of an Infected Endometrioma: A Case Report

Background. Endometriosis is defined as a chronic, inflammatory, estrogen-dependent gynaecologic disease. It affects approximately 5–10% of reproductive-age women worldwide. Ovarian endometriosis is the most frequent form of this condition. Endometriotic cysts are found in about 17–44% of women diagnosed with endometriosis. It is well known, that ovarian endometriomas can cause infertility and chronic pelvic pain. Enlarging cysts can also cause ovarian torsion. In addition, ovarian endometriosis slightly increases the risk for ovarian cancer. The rupture of endometriotic ovarian cysts is an exceptional complication. According to the literature, the prevalence is less than 3% among women with endometriosis. The rupture of an ovarian endometrioma can cause acute peritonitis, which can lead to sepsis, septic shock and can be lethal. The occurrence of abscesses within an ovarian endometrioma is an extremely rare complication. Generally, the origin of infected endometriotic ovarian cysts is related to the previous invasive procedures involving pelvic organs or the use of intrauterine devices. Also, ovarian abscesses can be caused by the hematogenous or lymphatic spread of bacteria. Although, the literature points out that infection of endometriotic ovarian cysts can develop spontaneously. In these rare cases, reservoir and route of infection remains an enigma.Case report. A 49-year-old female was brought to the emergency room with severe generalized lower abdominal pain (6/10) and three days lasting fever. Abdominal examination revealed diffuse abdominal pain with anterior abdominal wall muscle tension. Painful solid masses were felt on both sides of the uterus during the pelvic examination. Cystic masses were detected in both ovaries during transvaginal sonography. Computer tomography (CT) of the abdomen and pelvis revealed abnormal changes in both ovaries. A small amount of free fluid was found in the pelvic cavity along with thickened pelvic peritoneum. Suspecting acute peritonitis and bilateral tubo-ovarian abscesses, surgical treatment was performed. Lower midline laparotomy with bilateral adnexectomy and abdominal lavage with 4000 ml normal saline were done. The outcome of peritonitis was evaluated using the Mannheim peritonitis index (MPI=17 – low risk of morbidity and mortality). The histopathological examination revealed the diagnosis of bilateral endometriotic cysts complicated with acute inflammation, with associated acute inflammation of both fallopian tubes. Microbiological cultures from the purulent fluid were negative.Conclusions. Although the occurrence of abscesses within an ovarian endometrioma is an extremely rare finding in clinical practice, it has to be considered by gynaecologists because it might result in a surgical emergency that can be life-threatening. Being aware of the risk factors of abscesses within an endometrioma can lead to an early diagnosis of this rare condition and help to avoid serious complications.

Metabolic Associated Fatty Liver Disease in Children—From Atomistic to Holistic

Non-alcoholic fatty liver disease has become the most common chronic liver disease in children due to the alarmingly increasing incidence of pediatric obesity. It is well-documented that MAFLD prevalence is directly related to an incremental increase in BMI. The multiple hits theory was designed for providing insights regarding the pathogenesis of steatohepatitis and fibrosis in MAFLD. Recent evidence suggested that the microbiome is a crucial contributor in the pathogenesis of MAFLD. Aside from obesity, the most common risk factors for pediatric MAFLD include male gender, low-birth weight, family history of obesity, MAFLD, insulin resistance, type 2 diabetes mellitus, obstructive sleep apnea, and polycystic ovarium syndrome. Usually, pediatric patients with MAFLD have nonspecific symptoms consisting of fatigue, malaise, or diffuse abdominal pain. A wide spectrum of biomarkers was proposed for the diagnosis of MAFLD and NASH, as well as for quantifying the degree of fibrosis, but liver biopsy remains the key diagnostic and staging tool. Nevertheless, elastography-based methods present promising results in this age group as potential non-invasive replacers for liver biopsy. Despite the lack of current guidelines regarding MAFLD treatment in children, lifestyle intervention was proven to be crucial in the management of these patients.

Ileosigmoidian knot about an observation at the Donka CHU National Hospital in Conakry

Introduction: The ileosigmoid node is a double volvulus involving the sigmoid and the small intestine. The preoperative diagnosis is difficult in our practice setting. We report a case of ileosigmoid node that we discuss with data from the literature. Observation: This was a 40-year-old man admitted for diffuse abdominal pain of progressive onset, paroxysmal, accompanied by cessation of materials and gas, profuse vomiting of food and hiccups, progressing for 24 hours. With a history of persistent constipation and episodes of sub-occlusion, clinical examination noted pain, abdominal distension and dullness of the flanks and inaudible peristalsis. The digital rectal examination noted an emptiness of the rectal bulb and a bulging of the Douglas. The biological assessment was unremarkable. The ASP showed an arched image. Confirmation was intraoperative with a small bowel volvulus around the sigmoid in the form of a node producing double ileal and sigmoid necrosis. We performed an ileo-ileal anastomosis resection and a left iliac colostomy using the Hartman technique. The postoperative follow-up was simple, the patient was discharged on D10 postoperative. Six weeks later the patient was readmitted for restoration of colonic continuity. Five months later, no complaints were reported. Conclusion: The ileo-sigmoid node is a rare cause of intestinal obstruction, difficult to diagnose preoperatively in our exercise setting, the progression is rapid towards digestive necrosis. The availability of emergency CT examinations and early management of this condition would improve the prognosis.

Medical Management of Pyometra in the Delayed Postoperative Period

Pyometra is a rare condition in which purulent material becomes entrapped within the uterine cavity. If unrecognized in a timely fashion, life-threatening complications can arise. The following is a case report of a 50-year-old female who presented to the emergency department with abdominal pain and heavy vaginal bleeding. She was diagnosed with a pyometra based on imaging and treated conservatively with antibiotics. The patient ultimately had an uncomplicated hysterectomy with resolution of normal female pelvic anatomy prior to surgery. Pyometra should be considered when women present with diffuse abdominal pain or peritonitis. As demonstrated in this report, early detection and conservative management may help prevent serious complications such as uterine perforation, lead to shorter hospital stays, and result in safer operative management.

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.

Antiphospholipid Antibody Syndrome Presenting as Subacute Abdominal Pain Due to Portomesenteric Thrombosis

Antiphospholipid antibody syndrome (APS), a hypercoagulable state, affects organ by causing venous or arterial thrombosis. We present an unusual case of a 58-year-old male who presented with diffuse abdominal pain and on evaluation diagnosed as having portomesenteric venous thrombosis due to primary APS. Upon successful treatment with enoxaparin followed by anticoagulants for 6 months, recanalization of the portal vein was documented by endoscopic ultrasonography. Early identification and treatment of portomesenteric thrombosis is crucial to prevent bowel ischemia. Lifelong anticoagulation with vitamin K antagonists should be considered in those patients with major thrombosis and established APS.

A rare case of intestinal obstruction in pregnancy

Intestinal obstruction (IO) in pregnancy is rare at 1 in 2500 to 1 in 16709 deliveries with an incidence of 0.001% to 0.003%. Although uncommon, IO in pregnancy carries significant maternal (6%) and fetal (26%) mortality. A 30-year-old, primigravida, at 33weeks 4 days of gestation presented to the emergency obstetrics department of Swaroop Rani Nehru Hospital, Prayagraj, Uttar Pradesh, India with a 2-day history of diffuse abdominal pain, distension and obstipation. The decision of emergency caesarean section was taken and a 2.5kg healthy female baby was delivered. Surgical opinion was sought intraoperatively. Segmental resection and anastomosis, adhesiolysis and appendicectomy was done. Patient discharged on 10 post-operative day along with her baby in satisfactory condition. Diagnosis of SBO can be difficult to make as symptoms are often attributed mistakenly to pregnancy and there can be a reluctance to request plain films owing to the risks of ionising radiation. Both of these factors can lead to a delay in diagnosis and initiating treatment. Clinical suspicion is vital and joint management between surgeons and obstetricians is crucial. In agreement with previous literature reviews regarding the need for prompt laparotomy in most cases of SBO, we recommend that patients with confirmed adhesional obstruction may be managed conservatively in the first instance but with a low threshold for progressing to laparotomy.