Rectus muscle haematoma is a well documented clinical entity, but its diagnosis remains elusive. A haematoma within the rectus sheath produces a painful, tender swelling that can mimic an intraperitoneal mass with features of an acute abdomen. Two patients with rectus haematomas presenting after bouts of prolonged coughing are reported. In both cases, clinical features and ultrasound findings suggested the presence of intraperitoneal pathology. However, in both cases consistent findings in the history and examination pointed towards the diagnosis of a rectus haematoma. It is proposed that these simple clinical criteria are diagnostic of a rectus sheath haematoma, and can thereby avert an unnecessary laparotomy.
Peritoneal encapsulation is an exceedingly rare developmental abnormality in which the small intestine is encased in an accessory peritoneal sac between the omentum and mesocolon. Two clinical signs associated with the dense fibrous layer encapsulating the intestine are described. The first is a fixed, asymmetrical distension of the abdomen, which does not vary with peristaltic activity due to the unvarying position of the fibrous capsule. The second is the diVerence in the consistency of the abdominal wall to palpation. The flat area is firm, due to the dense fibrous capsule and the distended area soft, due to the thin walled distended small intestine with no overlying fibrous layer. (Postgrad Med J 2001;77:725-726)
A case of massive upper gastrointestinal bleeding in a 37-year-old female is presented showing a submucosal mass in the gastric body. At laparotomy a pedunculated submucosal mass was found located on the posterior wall at the junction of the body and antrum of the stomach, 8 cm from the pylorus. Pathology confirmed that it was a 4 cm benign gastric lipoma with a bleeding central ulcer. Gastric lipomas are rare, benign, typically submucosal tumors occurring in the gastric antrum. They are usually asymptomatic but can become symptomatic depending on size, location, and if there is ulceration of the lesion. These lesions may be mistaken as malignant tumors or present with upper GI bleeding or intussusception. The diagnosis can be made using a combination of upper endoscopy, endoscopic ultrasound, CT, and MRI with surgical excision being the definitive treatment of choice. We hope that this case highlights the fact that these lesions can present with massive upper GI haemorrhage and should be included in the diagnosis when appropriate.
Blunt abdominal trauma with intraperitoneal injury usually presents acutely. On rare occasions, such patients can present later on with features of small bowel obstruction due to stricture formation. It is thought that such a delayed stricture is due to subclinical bowel perforation, localised gut ischaemia, or injury to the mesenteric vasculature. This case demonstrates the mesenteric vascular injury theory to be the cause of the bowel stricture. B lunt abdominal trauma producing intraperitoneal injury usually presents acutely, necessitating laparotomy for intestinal perforation or mesenteric vascular injury.1 In the absence of shock and peritonism, patients with blunt abdominal injury may be treated conservatively. On rare occasions, such patients can present later on with features of small bowel obstruction.2 3 Delays in presentation between the initial insult to the abdomen and the obstructive episode have been documented to be as long as 26 years in the European literature. 4The exact pathophysiology is unclear, with three possible causes cited-subclinical small bowel perforation, localised bowel ischaemia, and mesenteric vascular injury. 5 We report the case of a 22 year old man who presented with small bowel obstruction two years after blunt abdominal trauma. Laparotomy revealed distal ileal stenosis with vascular mesenteric injury. This case reinforces the mesenteric vascular injury theory as the cause of the bowel stricture. CASE REPORTA healthy 20 year old man presented to the General Hospital, Port-of-Spain, having been involved in a motor vehicle accident one hour beforehand. He was the driver of a car that smashed into the rear of a stationary vehicle at low velocity. He was wearing a lap and shoulder belt at the time.Though he sustained blunt abdominal injury, bruising or the seatbelt sign were not evident. He was found to be stable with minimal abdominal tenderness. He was observed for a 24 hour period and subsequently discharged.He was seen repeatedly in the outpatient clinic for vague colicky abdominal pains which he had not experienced before injury. No investigations were ordered. Two years after the initial injury he presented to the surgical service with vomiting and constipation. His abdomen was mildly tender and grossly distended with increased bowel sounds. Plain abdominal radiographs revealed small bowel distension involving the jejunum and ileum.A laparotomy was performed and a stricture of the terminal ileum was observed. The adjacent mesentery was scarred and the mesenteric arterial pulsations were impalpable (fig 1). On table Doppler assessment revealed reduced biphasic arterial impulses within this segment of mesentery.The stenosed segment of ileum was resected and an end to end anastomosis performed. The specimen was examined histologically, revealing mucosal ulceration of the gut and degenerative infiltration of the mesenteric vessels.The patient was discharged after an uneventful postoperative course, and has remained symptom-free after five years.
Background:We sought to determine the association between the presence of a fecalith and acute/nonperforated appendicitis, gangrenous/perforated appendicitis and the healthy appendix. Methods:We retrospectively analyzed appendectomies performed between October 2003 and February 2012. We collected data on age, sex, appendix histology and the presence of a fecalith.Results: During the study period, 1357 appendectomies were performed. Fecaliths were present in 186 patients (13.7%). There were 94 male (50.5%) and 92 female patients, and the mean age was 32 (range of 10-76) years. The fecalith rate was 13%-16% and was nonexistant after age 80 years. The main groups with fecaliths were those with acute/nonperforated appendicitis (n = 121, 65.1%, p = 0.041) and those with a healthy appendix (n = 65, 34.9%, p = 0.003). The presence of fecaliths in the gangrenous/perforated appendicitis group was not significant (n = 19, 10.2%, p = 0.93). There were no fecaliths in patients with serositis, carcinoid or carcinoma. Conclusion:Our data confirm the theory of a statistical association between the presence of a fecalith and acute (nonperforated) appendicitis in adults. There was also a significant association between the healthy appendix and asymptomatic fecaliths. There was no correlation between a gangrenous/perforated appendix and the pres ence of a fecalith. The fecalith is an incidental finding and not always the primary cause of acute (nonperforated) appendictis or gangrenous (perforated) appendicitis. Further research on the topic is recommended.
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