Double Omental Hernia: A Case Report and Literature Review

Introduction: Celiac disease, or gluten-sensitive enteropathy, is a chronic disease of the digestive tract characterized by the inability to tolerate gliadin. Characteristic presenting symptoms include chronic diarrhea, abdominal, anemia. Although common in pediatric literature, intussusception as a presenting symptom of celiac disease in adults is becoming recognized. Our case adds to this growing body of evidence. Case Report: 54-year-old female with no reported past medical history initially presented to an outside physician with complaint of sudden onset of abdominal pain and some associated nausea. CT scan of the abdomen revealed small bowel intussusception with a transition point in the proximal small bowel. Initial laboratory including hemoglobin was unremarkable. The patient underwent an endoscopy, which revealed diffuse moderately scalloped mucosa in the first through the third part of the duodenum (Figure 1). Biopsies taken, as well as serologic testing, subsequently confirmed the diagnosis of celiac disease. The patient was advised to consume a gluten-free diet and to follow with a gastroenterologist as an outpatient. She is currently asymptomatic.Figure 1Discussion: Celiac disease is a disease that affects 1% of the population in the United States. Celiac disease can present infrequently as an acute abdomen. Approximately 3-10% of patients with celiac disease are diagnosed with acute abdomen. The most common causes of acute abdomen are intestinal perforation, complication related to lymphoma, volvulus and intussusception. In a recent study of patients with intussusceptions seen on imaging only, approximately 0.3% associated with a diagnosis and of these only three patients had confirmed celiac disease as a cause. Literature review of intussusception and celiac disease reveals several reports. However, these patients had additional symptoms and lab abnormalities. We report here acute abdomen as the only manifestation of celiac-related intussusception. Our case suggests that adult patients presenting with idiopathic intussusception should have a work-up for celiac disease.

Even if acute abdomen is associated with gastrointestinal (GI) perforation in more than 90% of cases, spontaneously perforated pyometra is a rare and misleading cause that gynecologists and general surgeons should suspect in elderly postmenopausal women. We report one case of diffuse peritonitis caused by spontaneous uterine perforation. A 94-year-old postmenopausal female was admitted to emergency department with signs of diffuse peritonitis and seven days history of abdominal pain. Abdominal contrast- enhanced CT-scan showed a large amount of ascites and a small amount of intraperitoneal free-air. One hour after the admission septic shock developed and emergency laparotomy was performed for suspected GI perforation. During laparotomy about 1500 mL of purulent, malodorous but not-fecaloid fluid was found in peritoneal cavity, without evidence of GI perforation. A 10 mm perforation on the anterior part of the uterine fundus was found. A total abdominal hysterectomy with a bilateral salpingo-oophorectomy was performed. Patients died on postoperative day four despite intensive care for multi-organ failure due to septic shock. The hysto-pathology examination showed absence of cancer. Pyometra perforation is a rare cause of acute abdomen with a not negligible mortality and it should be considered in the differential diagnosis of acute abdomen, especially in elderly patients. The aim of the study is to report our personal experience and a review of the literature of spontaneous perforation of pyometra in patients with no evidence of malignancy.

Omental torsion is a rare cause of acute surgical abdomen. It is caused by twisting of omentum along its long axis ending up in vascular compromise. In computed tomography presence of concentric streaks in the omental fat which is termed as ‘whirl sign’ is characteristic for torsion, although it can not be visualised if the rotation axis is not perpendicular to the examination plane. We present the tomography findings of a 71 year-old male patient with surgically correlated omental torsion in the right lower quadrant hernia sac. With this case we define ‘mushroom sign’ to describe the omental torsion with internal hyperdense streaks around the vascular pedincle in the hernia sac.

Torsion of the lesser omentum in a child

급성 복증(acute abdomen)은 갑자기 발생하는 심한 복부 통증으로 즉각적인 수술적 치료를 필요로 할 수도 있는 상태를 말한다. 소아 환자의 급성 복증의 원인은 다양하며, 수술적 치료를 해야 하는 질환부터 투약 치료를 받아야 하거나 임상적 관찰 만을 요하는 질환까지 다양하게 분류될 수 있다. 이러한 급성 복증의 환자에서 영상 검사의 역할은 가능하다면 복통의 원인이 되는 질환을 밝혀서 수술적 치료를 해야 하는 환자와 투약 치료를 해야 하는 환자를 구분해 주는 것이다. 장중첩증과 충수돌기염이 소아 환자에서 수술적 치료를 필요로 하는 급성 복증의 가장 흔한 원인 질환이므로, 급성 복통을 호소하는 영아에서는 장중첩증을, 좀 더 나이가 많은 소아에서는 충수돌기염을 영상 검사를 이용해 배제해 주는 것이 중요하다. 이 논문에서는 영유아 환자의 급성 복통을 유발할 수 있는 질환 중 특징적 영상 소견을 보이는 장중첩증, 충수돌기염, 중장 염전, 메켈 게실 및 중복낭종에 대해 소개하고자 한다

Greater omental torsion is a rare entity that can cause acute abdominal pain, may mimick other abdominal pathologies, and is difficult to be diagnosed preoperatively. We present a case of a male patient with greater omental torsion mimicking the symptoms of acute appendicitis. A 31-year-old male patient presented with right scrotal pain, initially treated by the urologists, however, 24 h later, he presented right lower quadrant pain, with characteristics of acute appendicitis. After finding in ischemic inflammatory mass on McBurney incision, an exploratory laparotomy was performed, revealing torsion of the greater omentum. Torsion of the greater omentum can be a cause of acute abdomen and could be misdiagnosed with acute appendicitis. Preoperative diagnosis is not easy and resection of the affected tissue is the preferred treatment of choice.

Non-operative management of diverticular perforation in a patient with suspected Ehlers–Danlos syndrome

Introduction Spontaneous perforation of the bile duct (BD) is a rare cause of acute abdomen in adults. Pre-operative diagnosis is challenging due to its non-specific presentation and the rarity of the condition. Method We present a case of a 66-year-old female who presented with right iliac fossa (RIF) pain and clinical signs suggestive of acute appendicitis. Laboratory investigations revealed raised inflammatory markers and mildly deranged liver function tests. CT imaging suggested perforated appendicitis with a possible free fecalith in the RIF. Results No evidence of appendicitis, small bowel, duodenal or gastric perforation could be identified during laparoscopy. Laparotomy and further exploration, revealed a 3 mm perforation was on the anterior surface of the mid-BD. A T-tube was utilized for biliary drainage and repair, and right paracolic drain; no cholecystectomy was performed. Patient had an uneventful recovery, however, serial T Tube cholangiograms up to 4 months later showed subclinical leak. Therefore, the T-tube was removed during ERCP, and a self-expanding-metal-stent was deployed. The patient developed mild post-ERCP pancreatitis and is awaiting elective cholecystectomy. Conclusions This case highlights the diagnostic difficulties of spontaneous BD perforation in adults. Total laparoscopic management is feasible if BD perforation is suspected. The slow healing observed may suggest an underlying ischemic component. Optimal drainage is essential if slow healing is potentially expected post operatively. Should the gallbladder be routinely removed during initial intervention? Is the use of silicone T-tubes optimal, or would latex T-tubes—due to their greater inflammatory response—facilitate more rapid healing through fibrotic tract formation?

Internal herniation is a rare cause of acute abdomen. If it is not diagnosed and treated in time, it can cause death. This case report discusses the clinical findings and surgical treatment of a case of left paraduodenal hernia, a rare cause of internal herniation. The diagnosis and treatment process of a 24-year-old female patient with ileus findings was retrospectively evaluated and presented in the literature. The patient was operated on with a preliminary diagnosis of internal herniation and the definitive diagnosis was made intraoperatively. At laparotomy, it was observed that almost all of the small intestines herniated posteriorly from the left paraduodenal region. Small intestinal loops were reduced and the hernia sac defect was primarily repaired. The patient was discharged on the fifth postoperative day with complete recovery. Left paraduodenal hernia is a type of internal herniation that should be considered in the differential diagnosis of patients with recurrent abdominal pain and intestinal obstruction. Surgical reduction and primary repair of the defect is an appropriate treatment.

La apendicitis del muñón es una causa poco común de abdomen agudo quirúrgico en niños, razón por la cual su diagnóstico no se sospecha con frecuencia. Este artículo reporta el caso de un paciente de dos años admitido en el servicio de urgencias por vómito, dolor abdominal y fiebre.Al ingreso, el paciente presentaba taquicardia, taquipnea, distensión abdominal y dolor difuso a la palpación del abdomen; los laboratorios evidenciaban leucocitosis, trombocitosis y elevación de la PCR. Inicialmente, se consideró obstrucción intestinal con base en antecedentes de peritonitis secundaria a una apendicitis perforada; sin embargo, debido al deterioro hemodinámico y al aumento del dolor abdominal, fue llevado a laparotomía exploratoria de urgencia.Durante el procedimiento se encontró peritonitis generalizada con apendicitis de la base, perforación intestinal, múltiples adherencias y, de forma incidental, un divertículo de Meckel. Se realizaron las intervenciones quirúrgicas correspondientes, y por su grave estado, fue hospitalizado en la unidad de cuidados intensivos (UCI), en donde recibió tratamiento con antibiótico de amplio espectro por 14 días y varios lavados peritoneales; por último, el paciente fue dado de alta satisfactoriamente.Aunque la apendicitis del muñón no es una causa frecuente de abdomen agudo, es necesario considerarla en aquellos pacientes con antecedentes de apendicitis y que ingresan por dolor abdominal, ya que la demora en el tratamiento se asocia con mayor morbilidad y aumento en los costos de atención.

Imperforate hymen a cause of acute abdomen and hydronephrosis in a15 year old girl: A case report. Abstract Imperforate hymen is a type of congenital vaginal outflow tract anomaly due to failure of perforation of the hymen. It is a cause of hematocolpos, hematometria and urinary tract obstruction due to the pressure effect of the hematocolpos. Case: A 15-year-old girl who presented at puberty with a history of primary amenorrhea, cyclical and acute abdominal pain with ultrasound features of hematocolpos, hematometria and hydronephrosis. The obstruction was relieved by the cruciate incision of the hymen. Conclusion: Acute abdomen in a pubertal girl with primary amenorrhea may be due to imperforate hymen

BackgroundAcute pancreatitis is one of the most common causes of acute abdomen. It is associated with multiple complications. Gastric perforation and isolated renal vein thrombosis are two infrequent complications. We present a case of acute pancreatitis with gastric perforation and isolated renal vein thrombosis in the same patient.Case presentationA 28-year-old gentleman with chronic alcohol intake presented with complaints of abdominal pain and not responding to analgesics. Biochemical investigations revealed elevated amylase and lipase level. Contrast-enhanced computed tomography (CECT) showed necrotizing pancreatitis with necrotic collection in the lesser sac. On oral contrast, active contrast extravasation from gastric perforation was picked up. Renal vein and splenic vein thrombosis was observed.ConclusionsGastric perforation and renal vein thrombosis are two infrequent complications of acute pancreatitis. High-end radiological suspicion is needed to reduce the associated morbidity and mortality.

Spontaneous perforation of the nonspecific small bowel ulcer is a rarely seen condition that causes acute abdomen and mostly diagnosed perioperatively. A 72-year old female patient was admitted to emergency service with abdominal pain. Her physical examination was compatible with acute abdomen and peritonitis. Abdomen computerized tomography showed free air under the right diaphragm. She was operated with a presumptive diagnosis of gastrointestinal perforation. An isolated jejunal perforation on the opposite side of the mesentery was found perioperatively. A biopsy was taken, and the perforation was repaired with primary sutures. The patient died in the intensive care unit due to pulmonary complications on the fifth postoperative day. Although the biopsy was taken from the superficial tissue, it was consistent with an ulcer. Nonspecific jejunal ulcer perforations can be life-threatening because of the delayed diagnosis. Especially in elderly patients, it should be kept in mind as a cause of acute abdomen.

Background Primary omental torsion is a rare cause of acute abdomen and is almost never diagnosed clinically. Laparoscopic management of this condition has been infrequently reported in the literature. Herein, we present a series of patients with omental torsion that presented as acute abdomen treated laparoscopically.

Abdominal pain and vomiting are the most common presentation of gastrointestinal tract disorders in children that lead to imaging. According to the suspected disease, the age of the child, and the institution's preferences, various imaging modalities, including radiography, US, barium study, or CT or MR have been used for examining the gastrointestinal tract. After the neonatal period, a different set of disorders involves the gastrointestinal tract in infants and children, sometimes producing acute abdomen. Intussusception is the most common cause of acute abdomen in infants and young children. Hypertrophic pyloric stenosis should be ruled out in a young infant with vomiting. A strangulated inguinal hernia, complicated Meckel’s diverticulum or necrotizing enterocolitis, and malrotation with volvulus are other causes of acute abdomen, both in the neonatal period and infancy. Acute appendicitis is the most common surgically treated condition in older children. Appropriate and judicious use of imaging techniques should be made by paying attention to clinical history and physical findings, which, in conjunction with knowledge of imaging findings of pediatric gastrointestinal disorders, will allow an early diagnosis to be made as well as guiding a proper treatment.