Electronic fetal monitoring in predicting cerebral palsy

A 58 year old man was admitted to the accident and emergency department following an industrial accident in which he sustained a three part fracture dislocation of his right humerus. Chest radiography revealed a large mass in the right upper hemithorax and, when the patient became hypotensive, an emergency thoracotomy was performed. The mass was found to be a massive intrathoracic lipoma. This case shows how preexisting intrathoracic lesions may be mistaken for subclavian or great vessel trauma following violent shoulder girdle injury. The differential diagnosis of traumatic and non-traumatic intrathoracic mass lesions in chest radiography should be considered carefully.     

1 MAC-incision sevoflurane prevents explicit awareness during surgical skin incision and tracheal intubation

A 34 year-old female patient was admitted to our hospital with left-sided abdominal pain. Physical examination, chest and abdominal X-rays led to the diagnosis of a colonic obstruction. Colonic gastrografin study showed the splenic flexure herniated into the left hemithorax. Bochdalek hernia was diagnosed and emergency operation was performed. Postoperative course was uneventful.     

Comparative efficacy of chloroquine plus chlorpheniramine and halofantrine in acute uncomplicated falciparum malaria in Nigerian children

A 47-year-old woman on long-term hemodialysis due to a chronic isolated abdominal aortic dissection was admitted to our department with severe abdominal pain. She had not suffered any hematemesis or melena. An emergency laparotomy revealed an abdominal aortic aneurysm with a diameter of 60mm, densely adhered to the ileum. An aortoenteric fistula manifesting as intramural rupture into the ileum was found after infrarenal abdominal aortic and bilateral common iliac cross-clamping. The fistula on the ileac side was nontransmural, but that on the aortic side communicated with the pseudolumen of the abdominal aorta, and contained mural thrombus. The infrarenal abdominal aorta and bilateral common iliac arteries were replaced with a collagen-sealed woven Dacron bifurcated graft. Histological examination of the ileum in this portion showed intramural bleeding and xanthomatous granulation with foam cell infiltration in the thickened subserosa. While it is difficult to diagnose nonpenetrating aortoenteric fistula preoperatively, such a fistula must be considered in a patient with severe abdominal pain, for whom previous abdominal aortic surgery has been performed or when an abdominal aneurysm is observed. To our knowledge, no other case of an aortoenteric fistula presenting as an intramural rupture into the ileum in an isolated abdominal aortic dissection has ever been reported.     

Video-assisted thoracoscopic closure of PDA--a case report and literature review

A 78-year-old man with a history of recent unexplained lower gastrointestinal bleeding presented to the emergency department with the acute onset of abdominal pain, tenesmus, and shock. Computed tomography of the abdomen showed a fistula between a common iliac artery aneurysm and the small intestine. Laparotomy demonstrated a saccular aneurysm of the common and proximal internal iliac arteries with fistulous communication to the distal ileum. Aneurysmectomy, arteriorrhaphy, and segmental ileal resection with primary anastomosis were successfully performed. This case illustrates a rare complication of an uncommon aneurysm, emphasizing the need for emergency physicians to consider complicated vascular disease in the evaluation of a patient with abdominal pain and shock.     

Jejunal perforation caused by blunt abdominal trauma in a patient with Crohn's disease: report of a case

We report herein the case of a 23-year-old man with Crohn's disease who was found to have a perforated small bowel following blunt abdominal trauma sustained in a traffic accident. The general findings of diffuse peritonitis were identified by physical examination, and a plain X-ray film showed free air in the abdominal cavity. An emergency laparotomy was performed which revealed three perforated ulcers in the affected intestine. An abrupt increase in intraluminal pressure due to the striking force of the steering wheel to the abdomen was assumed to have been the cause of these perforations.     

Decompensated acute gastric dilatation caused by a bulimic attack in anorexia nervosa

HISTORY AND CLINICAL FINDINGS: Abdominal pain developed after a bulimic binge in a 19-year-old girl with anorexia nervosa. She had unsuccessfully tried to induce vomiting. Physical examination showed no clinical sign of peritonitis, although there was diffuse abdominal tenderness on pressure. INVESTIGATIONS: There was leukopenia (2200 G/l) and a raised serum lactate level (58 mg/dl). No free air was seen on a plain film of the abdomen. Abdominal sonography revealed little free fluid subhepatically. TREATMENT AND COURSE: Acute respiratory impairment during investigations required emergency intubation. As bronchoscopy revealed aspiration a bronchial lavage was performed. Under gastroscopic control gastric emptying was achieved through a large gastric tube. After early improvement the patient developed the full picture of sepsis. Ultrasonography and needle puncture having revealed purulent intraabdominal fluid, a laparotomy was performed, which showed necrosis of the anterior and posterior walls of the stomach with free perforation. The greater curvature was resected. The patient slowly recovered but a relaparotomy for a subphrenic abscess became necessary on the 10th postoperative day. A year later there was free food passage, but the anorexia nervosa was unchanged. CONCLUSION: A bulimic binge can become life-threatening if the stomach does not empty spontaneously. Surgical intervention is required, if the patient's condition does not improve despite gastric emptying.     

The intake of proteins and essential amino acids in top-competing women athletes]

PURPOSE: The literature on diagnostic peritoneal lavage in the assessment of blunt abdominal trauma reflects an ongoing controversy. Therefore we conducted a prospective evaluation of the diagnostic management of blunt abdominal trauma used at our clinic, in which this procedure plays a substantial role. During the years 1993 and 1994 a total of 75 patients could be included in the study. The study population consisted of all patients with a diagnosis of blunt abdominal trauma. In addition, all trauma patients who were unresponsive on admission to the emergency receiving unit underwent the same program of diagnostic work-up. This group included polytraumatized patients, patients with craniocerebral injuries and all those who had been intubated prior to admission. Patients with stable vital signs were evaluated first by sonography of the abdomen, whereas those showing signs of hypovolemic shock received a diagnostic peritoneal lavage as the first evaluation of abdominal trauma. In order to assess the relative value of the two diagnostic methods, all patients who had had ultrasound as their first examination subsequently also underwent peritoneal lavage. RESULTS: 37 patients (49%) had lavage evidence of intraperitoneal bleeding. Of these 22 (29% of the total) subsequently underwent emergency laparotomy with lesions requiring surgical treatment found in 21 (95%). Only in one patient (1.3% of the study population) laparotomy failed to reveal a lesion requiring surgical correction. The accuracy of peritoneal lavage findings as an indication for laparotomy was 99%, compared to 82% for ultrasonography used as a initial diagnostic procedure. Diagnostic peritoneal lavage is quick, safe and almost independent of the experience of the investigating physician. It can be performed during other diagnostic procedures and can be repeated at will. If beyond macroscopical evaluation the lavage fluid is assessed chemically, even duodenal and pancreatic lesions as well as injuries to other hollow viscera can be suspected. With a sensitivity of 100% and a specificity of 98%, diagnostic peritoneal lavage is an extremely reliable diagnostic tool. It should be used as the initial diagnostic procedure in all hypovolemic and/or unresponsive patients suspected of having suffered blunt abdominal trauma. In conscious patients with stable vital signs, ultrasonography can be used for initial diagnosis. It should, however, be complemented by subsequent peritoneal lavage whenever the clinical course gives rise to suspicion.     

The value of physical examination in the diagnosis of patients with blunt abdominal trauma: a retrospective study

Between 1 January 1993 and 1 January 1994, 204 consecutive patients with possible blunt abdominal injury were analysed retrospectively. All patients underwent a standardized diagnostic approach on admission to the emergency room. Abdominal ultrasound (AUS) was performed in all cases. If there was evidence of intra-abdominal injury on physical examination or AUS, without signs of persistent hypovolaemia after initial assessment, contrast-enhanced computed tomographic scanning (CECT) of the abdomen was carried out without exception. Physical examination was equivocal in 13 and 3 per cent, respectively, of patients with 'isolated' abdominal trauma (N = 23) or with fractures of lower ribs 7-12 as a sole diagnosis (N = 30). In multiple injury patients (N = 95) or those with suspected 'isolated' head injury (N = 56), these figures reached 45 and 84 per cent, respectively. AUS (N = 204) revealed intra-abdominal injury in 20 per cent of patients, and CECT (N = 43) resulted in additional information in 49 per cent. Patients with 'isolated' head injury showed 9 per cent abnormalities on abdominal evaluation versus 32 per cent in multiple injury patients. In lower rib fractures (7-12) in multiple injury patients abdominal injury was diagnosed in 67 per cent of the cases. We conclude that: (1) negative findings following reliable physical examination of patients with 'isolated' head injury show very high values (NPV 100 per cent), but reliable physical examination is very infrequent (16 per cent); (2) NPV in lower rib fractures due to low energy impact is very high (100 per cent), with a reliable physical examination in most patients (97 per cent); (3) in patients with isolated abdominal trauma 87 per cent have a reliable physical examination with a moderately high NPV (71 per cent); (4) almost half the multiple injury patients have an unequivocal physical examination (45 per cent), with a high NPV following reliable physical examination for abdominal injury (85 per cent); (5) abdominal ultrasonography should be the first step in the radiological assessment of all patients with possible blunt abdominal injury; (6) in multiply injured patients with fractures of their lower ribs (7-12) due to high energy impact the incidence of abdominal injury is very high and CECT might be indicated even in the case of normal AUS findings.     

Operations in concomitant diseases of the abdominal organs

Under consideration are one-moment operations for associated lesions of abdominal organs. Based on the experience with 103 such operations, the authors subdivided patients into two groups: emergency operated patients and those in whom planned interventions were performed. It is believed by the authors, that a careful clinical preoperative examination of the latter and methodical revision of abdominal organs in urgent laparotomies make it possible to reveal an associated pathology of abdominal organs and to perform a radical one-moment operative procedure.     

Salt-sensitive hypertension induced by sensory denervation: introduction of a new model

OBJECTIVE: To determine whether surgeons and residents with minimal training can evaluate accurately emergency ultrasound (US) examinations compared with radiologists for blunt abdominal trauma. METHODS: Over 7 months, we conducted a prospective study comparing the evaluation of emergency US for blunt abdominal trauma by surgeons and attending radiologists. US readings from the surgical team and the radiologists were correlated with outcome. RESULTS: One hundred-twelve patients were included in the study. Ninety-two patients had an US read as negative by the surgical and radiology services with no subsequent injuries identified. Eighteen patients had an US deemed positive by the surgical service and radiologists. Injuries were confirmed in this group by operation or computed tomography. One patient had an US deemed positive by the surgical team and subsequently negative by the radiologist. A diagnostic peritoneal lavage was performed which was negative. Another patient had an US interpreted as negative by the surgical evaluator and positive by the radiologist. Exploratory laparotomy was negative for intraabdominal hemorrhage or organ injury. Overall results reveal an accuracy on US reading of 99% for the surgical team and 99% for the attending radiologists. CONCLUSION: Surgeons and surgical residents at different levels of training can accurately interpret emergency ultrasound examinations for blunt trauma from the real-time images, at a level comparable to attending radiologists.     

Blunt abdominal trauma

Assessment and management of patients with blunt abdominal trauma remains a challenge for emergency physicians. The spectrum of injury ranges from the trivial to the catastrophic and the initial assessment, resuscitation, and investigation of patients with abdominal trauma must be individualized. This article covers the important aspects of patient history and physical examination and addresses the relevant investigative tools available. An approach to the assessment of patients with abdominal trauma is provided; the goal is to diagnose significant injuries as soon as possible and avoid the pitfall of a delayed or missed diagnosis.     

Hepatic artery ligation for liver metastasis of a acinar cell carcinoma of the pancreas revealed by a nodular panniculitis

We report the case of a 67-year-old-man presenting with pancreatic acinar cell carcinoma revealed by dermatological manifestations of cytosteatonecrosis and treated by hepatic artery ligation. The pancreatic etiology of these lesions was suspected due to hyperlipasemia, and was confirmed by abdominal computerized tomography showing a pancreatic tumor and multiple liver nodules, and by histological examination of one of these lesions. Because of symptomatic treatment failure, rapid impairment of patient's general condition, and by analogy with the treatment of hepatic metastases of neuroendocrine tumors, hepatic artery ligation was performed. Lipasemia decreased markedly and symptoms disappeared for 45 days. Hepatic artery obstruction may be used for emergency treatment of secreting liver metastases.     

Kinetics of absorption, equilibration (or distribution), and excretion of orally and intraperitoneally administered cholesterol in the rat

Forty patients with abdominal injury and massive hemoperitoneum had left thoracotomy and thoracic aortic occlusion. All 40 patients had tense abdominal distention and 37 patients were hypotensive at the time of skin incision despite aggressive resuscitation with blood and crystalloid solution. Laparotomy was performed initially in 11 patients; seven patients had sudden cardiovascular collapse as the abdominal wall tamponade was released and four patients remained hypotensive. With thoracotomy and thoracic aortic occlusion six of the 11 patients were resuscitated and had their injuries repaired. Thoracotomy and thoracic aortic occlusion were performed before laparotomy in 29 patients: seven patients remained hypotensive and expired; blood pressure was promptly restored in 22 patients and 11 of them survived the operative procedure. Left thoracotomy and thoracic aortic occlusion, before laparotomy, is offered as an alternative approach in patients with refractory hypotension and tense, abdominal distention. This technique aids in rapid restoration of vital signs, insures continued perfusion of the brain and myocardium, provides proximal arterial control, and prevents sudden cardiac arrest as the abdominal wall tamponade is released.     

The politics of reconstructing the health sector and the informal health market: non-established links]

A 16-year-old Libyan male was admitted to the Intensive Therapy Unit (ITU) of Zliten Central Hospital after he had been hit on the abdomen by a football, his main symptom was upper abdominal pain. The patient looked pale, was dyspnoeic and had an unrecordable blood pressure level. Abdominal examination revealed tenderness, guarding and rigidity all over the abdomen. Other results were normal and there were no external signs of injury. The patient received intravenous fluid, analgesia and oxygen by mask. Peritoneal lavage was performed and a small amount of sero-sanguineous fluid was expelled. After resuscitation measures his blood pressure rose and the patient was taken to the operation theatre for a laparotomy.     

Large intestine obstruction complicated with perforation: a rare manifestation of Schistosoma mansoni infection

The authors report a case of a 25 year old Brazilian man with a history of crampy abdominal pain in the left iliac fossa for 2 weeks, abdominal distention, mucous diarrhea and anorexia. The patient presented signs of hemodynamic instability and a hard mass palpated in the left iliac fossa presented peritoneal irritation. At laparotomy, fecal peritonitis and a punched-out perforation of the midsigmoid colon were found. A left hemicolectomy was performed with terminal colostomy. Specimen examination revealed a thickened rectosigmoid wall, narrow lumen and multiple mucosal polyps. Microscopically, chronic granulomatous colitis with Schistosoma mansoni eggs confirmed the etiology. To the authors' knowledge, this is the first case of obstruction complicated with perforation due to mansoni schistosomiasis reported in the literature.     

Perforated solitary ulcer of the colon. Report of a case

PURPOSE: A patient with a solitary colonic ulcer had sudden onset of crampy abdominal pain, anorexia, fever, and vomiting, with signs of positive peritoneal irritation. METHODS: The diagnosis was proved by histopathologic examination of right hemicolectomy material. RESULTS: An emergency laparotomy, with right hemicolectomy and ileotransversostomy, gave complete relief from symptoms. The patient was still asymptomatic at the two-year follow-up, and control colonoscopic examinations performed at 6 and 18 months after the operation were normal. CONCLUSION: Preoperative diagnosis of perforated solitary colonic ulcers localized at the right hemicolon may mimic acute appendicitis, and intraoperative findings may mimic colonic carcinoma. If the preoperative diagnosis is not certain, right hemicolectomy and ileotransversostomy, with regular colonoscopic controls, is a safe procedure in the treatment and follow-up of these patients.     

Preparation for upper gastrointestinal endoscopy: opportunity or inconvenience?

A 59-year-old man, who manifested lower back pain, was admitted with sepsis and disseminated intravascular coagulation (DIC). A computed tomographic scan showed a slight thickening of the abdominal aortic wall. A blood examination revealed pancytopenia. Myelodysplastic syndrome was diagnosed after bone marrow aspiration and a chromosome analysis. Sepsis due to a Staphylococcus aureus infection and DIC subsided after medical treatment; however, an aortobifemoral bypass was performed upon the detection of a localized rupture of a mycotic abdominal aortic aneurysm 1 month later. The patient is still alive 2 years after operation despite the presence of a hematological disorder.     

A rare case of diplopia: medial inferior pontine syndrome or Foville's syndrome

A case of medial inferior pontine syndrome or Foville's syndrome is described. The patient presented to the emergency department with an acute history of slurred speech, vertigo and diplopia as major complaints. He also mentioned the appearance of weakness and numbness in his left leg. The physical examination revealed a crossed neurological deficit (ipsilateral cranial nerve deficit with contralateral motor weakness) which is typical for posterior circulation stroke in the brainstem territory. In our patient the lesion was located in the right medial inferior pontine region. All the symptoms and signs disappeared within 24 hours confirming the importance of a detailed physical and neurological examination of each patient presenting at the emergency department with a neurological deficit.     

Distinct clonal origin of low-grade MALT-type and high-grade lesions of a multifocal gastric lymphoma

PURPOSE: Renovascular hypertension is an unusual cause of elevated mean arterial pressure in children. When suspected, angiotensin-converting enzyme inhibitor-enhanced renal scintigraphy is usually one of the initial studies done to evaluate patients. The accuracy of this test depends not only on patient selection but also on technical factors involved in performing the study. We report a case of a false-positive angiotensin-converting enzyme inhibitor-enhanced radionuclide renogram in a 5-year-old boy with hypertension. METHODS: Angiotensin-converting enzyme inhibitor-enhanced renal scintigraphy was performed and the result was interpreted as positive for bilateral renovascular disease. A review of the anesthesia record from the study revealed that the patient was hypotensive. A repeated study with adequate hydration and blood pressure stability was then done. RESULTS: The result of the second examination was interpreted as normal, without evidence of abnormal renovascular physiology. CONCLUSIONS: The cause of the initial false-positive result was determined to be dehydration with secondary hypotension. Dehydration, with secondary hypotension, can cause a diminished glomerular filtration rate and mimic bilateral renovascular physiology on angiotensin-converting enzyme inhibitor-enhanced renal scans.     

Laparoscopic diagnosis of subcapsular splenic hematoma in a horse

A 5-year-old Quarter Horse was examined after it developed signs of abdominal discomfort as a result of a training accident. Oral mucous membranes were pale, and capillary refill time was > 3 seconds. Hematologically, the PCV was low, and abdominocentesis yielded a serosanguineous fluid. Abdominal ultrasonography was performed and revealed a large hypoechoic mass associated with the cranial margin of the spleen. Because differentiation between subcapsular hematoma and extracapsular hematoma could not be made with certainty, further evaluation of the spleen was indicated. Abdominal laparoscopy was performed, with the horse standing, to evaluate the extent, severity, and nature of the splenic hematoma. Laparoscopic examination revealed a 7.5-cm-diameter splenic hematoma contained within the splenic capsule, confirming the diagnosis of subcapsular splenic hematoma. Abdominal laparoscopy provided excellent observation of the spleen and allowed for thorough evaluation and determination of the extent of the lesion. This information aided the clinician in reaching a definitive diagnosis and choosing between splenectomy and medical treatment.