Painless spontaneous haemoperitoneum secondary to a uterine leiomyoma/fibroid: unusual presentation of a life-threatening differential

This is a case of a 47-year-old woman with a spontaneous haemoperitoneum secondary to uterine leiomyomas (fibroids), an important differential diagnosis in patients with uterine fibroids and hypovolaemic shock. Uterine fibroids are very common in women of reproductive age, yet little is taught about their potential to cause hypovolaemic shock. Although it is a rare complication, given the prevalence of fibroids, it is important to bear this life-threatening differential in mind to optimise the care for these women. Presentation typically involves abdominal pain, syncope, haemodynamic instability and an intra-abdominal mass. CT of the abdomen and pelvis can be helpful in identifying the source of the haemoperitoneum, but should not delay surgery, which is the definitive management.

Retrospective Study on Acute Kidney Injury among Cholera Patients in an Outbreak in Whitefield, Bengaluru

Introduction. Cholera is gastroenteritis caused by Vibrio cholerae. It presents with vomiting, severe secretory diarrhoea, and dehydration. It can cause severe complications with severe electrolyte imbalances and oligoanuric acute kidney injury due to acute tubular necrosis secondary to dehydration or infection itself. However, cholera presenting with significant proteinuria and acute kidney injury has not been reported. Hence, this study was conducted. Aims and Objectives. This aim of this study was to assess clinical features, treatment, and prognosis of AKI in cholera patients; to correlate proteinuria with AKI in cholera patients; and to compare cholera patients with normal kidney function and those with AKI. Material and Methods. It was a retrospective observational study involving patients with cholera. Information regarding cholera patients with acute kidney injury, proteinuria, and prognosis were collected. Results. Most of the patients had significant vomiting, moderate-to-severe diarrhoea, dehydration, and hypovolaemic shock. Cholera caused severe complications such as severe electrolyte imbalances including hyponatraemia and hypokalaemia, acute kidney injury, and proteinuria secondary to dehydration or infection. A surprising finding noted was the lack of significant association between the onset of acute kidney injury and usual risk factors such as hypovolaemic shock and dehydration. It was found that proteinuria had influenced the onset of acute kidney injury, but it did not influence recovery. As there was complete recovery in kidney function, none of the cases required kidney biopsy. There was no mortality noted. Conclusions. This study points towards the rare occurrence of proteinuria and acute kidney injury in Vibrio cholerae infection with spontaneous remission of kidney disease with appropriate therapy.

Hypovolaemic shock due to intra-abdominal haemorrhage from multiple uterine fibroids

Intra-abdominal bleeding due to uterine fibroids is extremely rare, and preoperative diagnosis is difficult. Herein, we report a case of preoperatively diagnosed hypovolaemic shock due to intra-abdominal haemorrhage, in which fatal sequelae were prevented. A 46-year-old non-pregnant woman was brought to the hospital with a sudden-onset lower abdominal pain. On admission, she was in shock, and abdominal CT showed severe intra-abdominal haemorrhage. Since bleeding from uterine fibroids was suspected, an emergency simple total hysterectomy was performed, and her condition became stable after the operation. Intra-abdominal haemorrhage with hypovolaemic shock requires prompt surgical intervention. Although it occurs very rarely due to bleeding from uterine fibroids, imaging shows large fibroids; if the patient is not pregnant, bleeding from the fibroids should be considered.

Iliopsoas Hematoma Mimicking Femoral Neuropathy

Iliopsoas hematoma should be considered in the differential diagnosis of femoral neuropathy in patients who are on chronic warfarin therapy. It usually presents with groin or thigh pain, and in rare instances, large bleeding may cause hypovolaemic shock. Conservative management has a good clinical and neurological outcome in such cases.

Comparison of the previous and current trauma-related shock classifications – The more the better? – A retrospective cohort study from a level I trauma centre

Background: The aim was to compare the predictive performance of the current, extended (VS+BD) Advanced Trauma Life Support (ATLS) classification for hypovolaemic shock over the previous, vital sign (VS)-based classification with respect to mortality outcomes. We also studied the prognostic values of heart rate (HR), systolic blood pressure (SBP), Glasgow Coma Scale (GCS) and base deficit (BD).Methods: The present study is a retrospective analysis at a level I trauma centre between 11 July 2014 and 11 September 2019. Trauma patients (inclusion criteria: trauma team activation, transport directly from scene, no need for resuscitation on scene, precise and detailed medical documentation, age ≥16, 30-day follow-up, complete dataset for HR, SBP, GCS and BD) were allocated to shock classes (I–IV) based on the VS and VS+BD criteria. The predictive values for the classifications were compared with a two-proportion Z-test, while individual parameters were examined with receiver operating characteristic (ROC) analyses.Results: A total of 156 patients met the inclusion criteria out of 60,037 trauma admissions. Both the VS and VS+BD classifications have shown a strong relation to mortality (P=0.0001 vs. P=0.000009). There was no significant difference in their predictive performance. According to the statistical analysis, GCS, BD and SBP showed significant prognostic values (AUCGCS=0.799 [CI: 0.722, 0.875]; AUCBD=0.683, [CI: 0.576, 0.790]; AUCSBP=0.633, [CI: 0.521, 0.744]). HR was found ineffective in predicting mortality. Conclusions: The current ATLS classification for hypovolaemic shock did not appear to be superior to the previous, VS-based classification in our study setting. GCS, BD and SBP were proven to be useful parameters in prognosticating outcome. The role of HR should be reconsidered, since it does not seem to reflect the clinical condition accurately.

Shock

This chapter discusses shock and includes a definition and diagnosis, discussion on hypovolaemic shock (including causes of hypovolaemic shock, therapy, and the reperfusion phase), cardiogenic shock, anaphylactic shock (including pathophysiology), and pathophysiology of sepsis and multiorgan failure.

Aorto-oesophageal fistula: a late complication of Boerhaave syndrome

A 68-year-old woman presented with haematemesis and chest pain 3 months after a spontaneous oesophageal perforation. The patient rapidly progressed to a state of hypovolaemic shock and after resuscitation was found to have aorto-oesophageal fistula on CT aortogram. The patient was treated with a successful thoracic endovascular aortic repair.