Diagnostic Peritoneal Aspirate Revisited: Its Diagnostic Accuracy for the Detection of Intraabdominal Hemorrhage

Background The use of Focused Assessment with Sonography for Trauma (FAST) in combination with computed tomography (CT) has become the mainstay of diagnostic workup in patients with suspected intraabdominal hemorrhage (IAH). However, diagnostic peritoneal aspirate (DPA) can be an important adjunct in hemodynamically unstable patients. The aim of this study was to evaluate the utility and diagnostic accuracy of DPA in detecting IAH. Methods Retrospective analysis of all patients who presented to the LAC+USC Medical Center and underwent evaluation with DPA between January 2010 and December 2016. Intraoperative, CT, and autopsy findings were used as gold standards in determining the diagnostic accuracy of DPA for the detection of IAH. Results A total of 73 consecutive patients were included in the study. The median age was 42 years (interquartile range [IQR]: 25-56), median injury severity score was 29 (IQR: 21-41), and 82.2% sustained blunt trauma. The most common indications for DPA were hemodynamically unstable patients with suspected IAH and patients with return of spontaneous circulation following resuscitative thoracotomy. Overall, the positive and negative predictive values of DPA were 89.4% and 88.9%, respectively. In 14 cases (19.2%), DPA correctly identified false positive/negative FAST results. Conclusion Our data suggest that DPA has high diagnostic yield for IAH. The use of DPA should be considered in unstable patients with inconclusive FAST results who cannot safely be evaluated with CT.

Biliary Stenting Prior to Pancreaticoduodenectomy and its Effects on Postoperative Outcome. Twenty Years of Experience with 805 Patients

Background: The aim of this study was to evaluate the potential effects of biliary drainage before pancreaticoduodenectomy on postoperative outcomes. Methods: This study was conducted retrospectively on data from 820 cases of pancreaticoduodenectomy performed in the Gastrointestinal Surgery Department of Ankara City Hospital between April 1999 and August 2019. Twenty years of collected patient data were re-examined and 805 patients were divided into two groups as those who underwent preoperative biliary drainage (PBD) and those who did not (non-PBD). Demographic data of patients, and preoperative, operative and postoperative details, including morbidity, were collected and compared between the two groups. Results: There were 574 (71.3%) patients in the PBD group and 231 (28.6%) patients in the non-PBD group. Total complications according to Clavien-Dindo classification were significantly higher in the PBD group (P<0.001). Intraabdominal hemorrhage, delayed gastric emptying and wound infection were found to be higher in the PBD group but the rate of pancreatic fistula was similar in both groups. There was no difference between the two groups in terms of complications according to preoperative bilirubin levels. In drained patients with normal bilirubin levels, wound infections were significantly higher in a group with diameter of common bile duct>8 mm (P=0.020). Conclusion: PBD is not associated with anastomotic leakage after pancreaticoduodenectomy. Wound infection, delayed gastric emptying and intraabdominal hemorrhage were significantly associated with PBD. Preoperative bilirubin level had no effect on these results. In subgroup analysis, in patients undergoing drainage, if bilirubin falls below 5 mg/dL, the risk of wound infection was still high in patients with bile duct diameter>8 mm.

Dysfunctional labor and hemoperitoneum secondary to an incidentally discovered dysgerminoma: a case report

Background Ovarian dysgerminoma, a subtype of malignant germ cell tumor (GCT), is a rare ovarian neoplasm that is infrequently found in the gravid patient. When dysgerminomas do occur in pregnancy, the rapidly growing tumors can have a heterogeneous presentation and lead to peripartum complications and morbidity. Due to the rarity of this condition, diagnostic and therapeutic strategies are not well described in the literature. Case presentation A healthy multigravida with an uncomplicated antenatal history presented for elective induction of labor. She had a protracted labor course, persistently abnormal cervical examinations, and eventually developed a worsening Category II tracing that prompted cesarean birth. Intraoperatively, a 26 cm pelvic mass later identified as a Stage IA dysgerminoma was discovered along with a massive hemoperitoneum. The mass was successfully resected, and the patient remains without recurrence 6 months postoperatively. Conclusion Although rare and generally indolent, dysgerminomas can grow rapidly and cause mechanical obstruction of labor and other complications in pregnancy. Pelvic masses, including malignant neoplasms, should be included in as part of a broad differential diagnosis when evaluating even routine intrapartum complications such as abnormal labor progression. Additionally, we demonstrate that adnexal masses can be a source of life-threatening intraabdominal hemorrhage.

MODERN CONCEPT OF RENDERING AID TO WOMEN WITH OVARIAN APOPLEXY

Purpose. Analysis of rendering the medical aid to women with apoplexy of the ovary, determination of the basic clinical, laboratory and ultrasonic criteria, which influence the choice of therapeutic tactics, the evaluation of the immediate and long-term results of treatment of ovarian hemorrhages. Materials and methods. There was studied medical aid to 888 women with apoplexy of the ovary from 2012 to 2020. Depending on the volume of hemoperitoneum patients were divided into three groups: І group — 480 (54.0 %) patients whose volume of hemoperitoneum did not exceed 200 ml; ІІ group — 283 (31.8 %) women with intraperitoneal hemorrhage with volume from 200 to 500 ml; ІІІ group — 125 (14.1 %) patients with a volume of hemoperitoneum of more than 500 ml. The group І consisted of ІC group — 270 (30.4 %) women who were given conservative treatment of apoplexy of the ovary (AO), and ІL group — 210 (23.6 %) patients whose main diagnostic and treatment measure was laparoscopic intervention. Results of the study. The average age of the patients was (28.3±5.2). The pelvic pain was the leading clinical symptom in all patients. According to the data of the transvaginal US made in the saggital plane, a linear dependence was observed between the level of free liquid and the volume of hemoperitoneum (r=0.63, p<0.05). In 792 (89.2 %) patients the diagnosis of apoplexy of the ovary and intraperitoneal hemorrhage was made to surgical intervention — on the basis of clinical picture and US data. In the remaining cases — 92 (10.4 %) diagnostic laparoscopy was required for confirming the diagnosis. The average volume of hemoperitoneum discovered in patients with AO, in absence of the adhesive process was (273.5±21.3) ml, whereas in patients with the expressed adhesive process of the small pelvis organs it was (141.4±35.5) ml. The cause of AO was the corpus luteum or cyst of the corpus luteum in more than the half of the cases — 348 (56.3 %). Conclusions. The manifestation of the clinical symptoms in apoplexy of the ovaries depends on the volume of intraperitoneal hemorrhage. The data analysis of transvaginal echography allows to determine quantitatively, with a high degree of accuracy the volume of intraabdominal hemorrhage and the morphological state of the affected ovary. Laparoscopy is not only a “gold standard” in diagnosis and treatment of AO, but also contributes to the prevention of ovarian hemorrhages in future.

Morphological changes in the fallopian tubes in patients with ectopic pregnancy

Relevance. Ectopic pregnancy is an urgent condition which may lead to intraabdominal hemorrhage and woman death. In recent years, the frequency of this pathology is significantly increasing. However, morphological changes in the fallopian tubes in patients with this disease remain understudied. Aim. To study morphological changes in the fallopian tubes in patients with ectopic pregnancy with various variants of the clinical course. Materials and methods. The morphological study included 130 patients who had laparoscopic surgery for ectopic pregnancy. Comprehensive morphological study of the fallopian tubes removed during surgery was conducted. Results and discussion. The article presents the morphological changes in the fallopian tubes in patients with ectopic pregnancy. Implantation of a fertilized egg in the fallopian tube led to significant changes in its macro- and microstructure, which were due to invasion of the chorionic villi and involved all layers of the tube wall, differing only in depth and prevalence. The most pronounced morphological changes in various segments of the tube were revealed in the endosalpinx. Conclusion. The combination of morphological changes in different layers of the tube is related to a chronic non-specific productive endomyosalpingitis with luminal deformation, which was one of the main causes of this disease development.

A Delayed Diagnosis of Hemorrhagic Shock in a Patient with Alcoholic Cirrhosis and Ascites on Bedside Ultrasound

Undifferentiated shock is a common and challenging problem in critical care. We present a case of hemorrhagic shock due to splenic and hepatic lacerations diagnosed by bedside paracentesis, initially misclassified as septic shock due to suspected spontaneous bacterial peritonitis (SBP). Case. A 47-year old man with a history of reported alcoholic cirrhosis and ongoing heavy alcohol use was brought to the emergency room after a syncopal event. He was found to be anemic (hemoglobin 9.9 g/dl) and hypotensive with a blood pressure of 64/34. Despite crystalloid infusion he remained hypotensive and required vasopressor support with norepinephrine. Bedside ultrasound revealed moderate ascites and as there was no evidence of active bleeding, his shock was attributed to sepsis due to SBP. A bedside paracentesis was performed which revealed gross blood. A repeat hemoglobin returned at 4.4 g/dl. Massive transfusion protocol was initiated and interventional radiology was emergently consulted due to concerns for intraabdominal hemorrhage; general surgery deemed the patient too unstable for surgical intervention. Angiogram revealed a splenic laceration and possible hepatic laceration, both embolized successfully. Internal medicine practitioners should keep the differential of hemorrhagic shock due to intraabdominal organ injury in mind for patients with undifferentiated shock.

Emergency laparoscopic cholecystectomy for intraabdominal hemorrhage in a patient with a left ventricular assist device: a case report

Background Continuous-flow left ventricular assist devices (LVADs), called “second generation LVADs,” have significantly improved the survival and quality of life outcomes. Accordingly, non-cardiac surgery in a patient with LVADs has required for conditions not directly related to their LVADs. And the management of bleeding in non-cardiac site remains one of long-term critical topics. Laparoscopic approach is useful in a patient with LVADs; however, there have been only few clinical reports. This report describes the first case of laparoscopic cholecystectomy (LC) for intraabdominal hemorrhage from the gallbladder serosa in a patient with LVADs. Case presentation A 56-year-old man with an LVAD had undergone LVAD (Jarvik 2000™; Jarvik Heart, Inc., New York, NY, USA) implantation at 53 years of age. He was in shock, and contrast-enhanced computed tomography revealed abdominal hemorrhage from the gallbladder serosa. Emergency laparoscopic cholecystectomy was performed. We could avoid injury of the LVADs driveline, which was located across the upper abdominal midline, near the right hypochondriac region, by laparoscopic approach. LVADs (Jarvik 2000) did not disturb the operating field because of its smaller size. There were no intra- and postoperative complications. Conclusions Laparoscopic approach is useful and safe in a patient with LVADs for abdominal surgery. We could perform LC for intraabdominal hemorrhage from gallbladder serosa safety.

Sclerosing angiomatoid nodular transformation presend nodulartransformation presenting witha bdominal hemorrhage: First report in infancy

A limited number of sclerosing Angiomatoid Nodular Transformation (SANT) have been reported in pediatric age. We describe the first case of SANT occurring in a nine-week-old female infant that was admitted to our unit for severe abdominal distension and rectal bleeding. Enlarged spleen was detected on physical examination. Laboratory investigations revealed severe anemia and coagulation abnormalities. Abdominal ultrasound and computed tomography revealed ascites and splenomegaly with a large mass at the lower medial splenic pole. A diagnosis of intraabdominal hemorrhage was presumed and an exploratory laparotomy was performed. A complete transformation of the giant splenomegaly to bossellated masses and multiple bleeding capsular ruptures without subcapsular hematoma were found and an urgent splenectomy was performed. At histology, a SANT was diagnosed (CD34, CD31, CD8 positivity). The postoperative follow up was uneventful. SANT may also occur in infancy with a potentially lifethreatening presentation. Splenectomy may represent the only treatment in severe cases.