Spontaneous Pneumothorax Mimicking Perforated Viscus in Covid-19 patient

Case presentation: A 65-year-old female diagnosed with COVID-19 developed worsening respiratory distress requiring invasive ventilation. Chest radiography post-intubation revealed air under the diaphragm, pneumomediastinum and subcutaneous emphysema. The case was referred to the surgical team for emergency laparotomy for suspected perforated viscus. Clinically, her abdomen was distended but there was no sign of peritonism. In view of the high risk of perioperative morbidity and absence of peritonism, a CT scan was done to rule out the cause of pneumoperitoneum. CT scan showed bilateral pneumothorax, presence of air in the extra peritoneum and retroperitoneum. There was no air in the peritoneum and no evidence of perforated viscus. She was treated conservatively with bilateral chest tube insertion. Unfortunately, she developed multiorgan failure and succumbed to death.

EP.TU.373What We Do In The Shadows: Night Surgical Registrars and Abdominal Pain

Aim Surgical cover at night differ according to hospitals and are often performed by junior registrars. This can be challenging as a certain amount of independence is required in decision making. Abdominal pain remains one of the most common surgical presentations in the Emergency Department. This study analyses the type of abdominal pain presentations that were reviewed overnight in a regional Australian hospital. Method All patient presentations requiring surgical review from 9.00pm to 7.00am over a period of 4 months are prospectively collected and analysed. Patient details collected comprised of gender, date of review, blood tests, imaging results, histopathology, and intra-operative findings. Results Of the 114 patients who presented with abdominal pain, the majority of them were undifferentiated abdominal pain (n = 20, 17.1%). This is then followed by appendicitis (n = 17, 14.5%), diverticulitis (n = 13, 11.1%), pancreatitis (n = 8, 6.8%) and cholecystitis (n = 6, 5.1%). Among the others, a total of 8 presentations required urgent surgical review which resulted in three emergency surgeries being performed overnight, a laparotomy for closed loop small bowel obstruction, a Hartmann's procedure and a laparoscopic appendicectomy on a septic patient. Conclusion Common presentations for abdominal pain overnight include undifferentiated abdominal pain, appendicitis, diverticulitis, cholecystitis and pancreatitis. Hence education for night surgical registrars should be focused on management of these common conditions and also on surgical emergencies such as closed loop bowel obstructions, septic patients and perforated viscus to ensure optimal patient outcome without the need for close supervision.

796 Chronic Pneumoperitoneum: Cause or Consequence of Pneumatosis Cystoides Intestinalis

Pneumatosis cystoides intestinalis (PCI), ‘gas cysts’ in the wall of the bowel, is a rare sign that can be found as a result of many different conditions, ranging from benign and asymptomatic, to life threatening. Its pathogenesis is not yet fully understood, and patients found to have PCI are treated in a heterogeneous manner. Pneumoperitoneum, however, is much more commonly seen by the General Surgeons, and most often occurs as a result of a perforated viscus; usually necessitating an emergent surgical intervention. Spontaneous pneumoperitoneum occurs very rarely, although it is seen more frequently with small bowel PCI, compared to large bowel PCI. We present here an unusual case of a patient with acute-on-chronic pneumoperitoneum and subsequently subacute small bowel obstruction associated with small bowel pneumatosis cystoides intestinalis. The patient also had extensive pan colonic and jejunal diverticulosis, although the area of perforation and PCI was discrete and located in the mid-ileum. It is unclear whether the patient had chronic pneumoperitoneum secondary to perforated PCI, or if the PCI developed secondary to an ileum perforation of unknown origin (fitting with the bacterial or mechanical theory of pathogenesis). The patient went onto to have an emergency laparotomy and small bowel resection 28 months after initial presentation and a trial of conservative management.

730 An Atypical Presentation of a Hernia: Gastro-Inguinal Hernia

Acute presentation of an inguinal hernia is a common presentation to general surgery in the United Kingdom (UK). Rarely intra-abdominal organs, outside of small bowel and colon, can present within an inguinal hernia e.g., appendix or bladder. There has been limited publication involving an incarcerated hernia containing the stomach. We present the case of an 84-year-old male with a background of COPD and hypertension who presented to Accident & Emergency with a three-day history of vomiting and diffuse abdominal pain. On examination, the patient had a distended abdomen with generalized peritonitis, and an irreducible non-tender inguinoscrotal hernia. A CT scan of the abdomen and pelvis demonstrated small bowel obstruction and gastric outlet obstruction secondary to a large incarcerated right inguinal hernia containing stomach. The patient rapidly deteriorated clinically, which led to a decision to palliate the patient. The patient died eight days after initial presentation. The cause of death was documented as likely perforated viscus in an inguino-scrotal hernia. This case illustrates the devastating prognosis of an acute presentation of an inguinal hernia containing the stomach. This should be considered a surgical emergency and immediate operative intervention should take place if the patient is clinically able to have surgery.

Facility of Origin Predicts Mortality After Colonic Perforation

Introduction Colonic perforation often requires emergent intervention and carries high morbidity and mortality. The objective of this study was to determine whether nonclinical factors, such as transition of care from outpatient facilities to inpatient settings, are associated with increased risk of mortality in patients who underwent emergent surgical intervention for colonic perforation. Materials and Methods Using the 2006-2015 ACS National Surgical Quality Improvement Program database, we identified adult patients who underwent emergent partial colectomy with primary anastomosis ± protecting ostomy or partial colectomy with ostomy with intraoperative finding of wound class III or IV for a diagnosis of perforated viscus. The outcome of interest was 30-day postoperative mortality. Univariate and multivariate analyses using logistic regression were performed. Results 4705 patients met criteria, of which 841 (17.9%) died. Univariate analysis showed that patients who died after emergent surgery for perforated viscus were more likely to present from a chronic care facility (13.4% vs. 4.4%, P < .0001) and had longer time from admission to undergoing surgery (mean 4.1 vs. 2.0 days, P < .0001. Logistic regression demonstrated that septic shock vs. none (OR 3.60, P < .0001), sepsis vs. none (OR 1.57, P = .00045), transfer from chronic care facility vs. home (OR 1.87, P < .0001), and increased time from admission vs. operation (OR 1.01, P = .0055) were independently associated with increased risk of death. Discussion Transfer from a chronic care facility was independently associated with increased mortality in patients undergoing emergent surgery for perforated viscus.

Primary percutaneous coronary intervention without stenting using excimer laser and manual thrombectomy in STEMI with duodenal ulcer perforation: a case report

Background ST-segment elevation myocardial infarction (STEMI) and peptic ulcer perforation are both medical emergencies that require urgent intervention. In case that these time-sensitive medical emergencies present concomitantly, it remains unclear which one should be treated first. Case summary An 85-year-old man with melaena, epigastric pain, and severe anaemia was transferred to our emergency department and diagnosed as having inferior STEMI based on electrocardiogram. Emergency coronary angiography (CAG) revealed severe stenosis with thrombus in the proximal right coronary artery. Immediate oesophagogastroduodenoscopy and abdominal computed tomography detected the presence of duodenal ulcer perforation. Primary percutaneous coronary intervention (PCI) without stenting using excimer laser coronary angioplasty and manual thrombectomy was performed under intravascular ultrasound (IVUS) guidance to avoid dual antiplatelet therapy (DAPT). After successful PCI, the perforated viscus was surgically repaired with a laparoscopic omental patch. On Day 7, endoscopic haemostasis treated the oozing of blood from the duodenal ulcer. On Day 21, follow-up CAG and IVUS showed residual stenosis with organized thrombus in the culprit lesion, in which a drug-coated stent was directly implanted. He was discharged with a favourable clinical course on Day 23. Discussion We judged that PCI should take precedence over the surgical repair of perforated duodenal ulcer in our case since STEMI was an immediate life-threatening compared to the perforated viscus which had no active exsanguination. Excimer laser coronary angioplasty with manual thrombectomy might be an adequate option to avoid stent deployment and subsequent DAPT in such complex scenarios.

The Girl With Rapunzel Syndrome

Rapunzel syndrome is a syndrome whereby a gastric trichobezoar (hair ball) extends through the pylorus, in the form of a long tail, to cause gastric outlet obstruction. It was first described by Vaughan et al. in 1968. The syndrome is mostly seen in young females with psychiatric illness. Presentations can be non-specific especially in the early stages. If left untreated it may leads to severe complications, which may include gastric ulceration, intestinal obstruction, perforated viscus and obstructive jaundice. Treatment is essentially surgical and psychiatric consultation is necessary to prevent relapses. We present the case of a 26-year-old mentally subnormal lady with gastric trichobezoar and provide a review of the literature.

First reported case series of Candida krusei peritonitis secondary to a perforated viscus

Candida peritonitis is associated with high mortality and multiple organ failure. With an evolving epidemiology of candidaemia indicating an increasing prevalence of rare Candida species worldwide, consideration of multidrug-resistant fungal pathogens as a cause of abdominal sepsis is paramount. We report three cases of Candida krusei as a cause of secondary and tertiary peritonitis. These cases highlight that the early use of an echinocandin class antifungal in patients not responding to standard regimens warrants consideration.