Falciform Ligament Appendagitis: A Rare Cause of Acute Epigastric Pain

Pancreatitis in pregnancy has a prevalence of 1.5/1500-4500 cases, constituting one of the most common acute abdomen wedges, with biliary origin in 70% of cases, triglycerides in 20% and other causes in the remaining 10%, including choledochal cyst (CC) as a rare cause with three previous reports in literature, which may have a fatal outcome with fetal loss in some cases. We report the case of a 25-year-old patient with 30.4 weeks of gestation (WOG) that arrived to emergency room with right upper quadrant and epigastric pain for the last 8 hours, associated with nausea and vomiting. No pathological background referred. At physical examination with jaundice, gravidic abdomen for 30.4 WOG pregnant, fetal movements presents, Murphy (+) and epigastric pain on deep palpation. Laboratories report total bilirubin (TB) 3.9 mg/dl and direct bilirubin (DB) 3.69 mg/dl Alkaline phosphatase (AP) 2038 IU/L Amylase 280 IU/L Lipase 1938 IU/L. Pancreatitis is confirmed and abdominal ultrasound (US) is requested to determine biliar origin. USG reports gallbladder of 9×4 cm, thin walls without filling defects, dilated intrahepatic bile duct and common bile duct cyst. Cholangiopancreatography Resonance Imaging (CPMR) concludes Todani I choledochal cyst of 17×9 cm, with displacement of duodenum, colon and pancreas. Due to gestation ongoing appropriate medical management with fluids and analgesics was started until remission of pancreatitis 72 hours later. After delivery at 34 WOG, cholecystectomy was performed with hepatico-jejunum Roux-Y anastomosis successfully. Histopathologic analisis reports inespecific inflammation without displasia or metaplasia. At four months follow-up patient is asymptomatic. Pancreatitis in pregnancy is a common cause of acute abdomen, rarely associated with choledochal cysts as the cause. Surgical resolution once pregnancy is over must be done as soon as possible by the high risk of adenocarcinoma degeneration and recurrent pancreatitis.

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.

Background: The role of diagnostic imaging is to determine whether the condition is medically or surgically treatable and, if possible, to diagnose the exact nature of the disease. Chest radiography is also commonly used to demonstrate extra-abdominal causes of acute abdominal pain, such as pneumonia. Ultrasonography is the initial choice of investigation that is likely useful to conclude for the following reasons, namely, it is relatively inexpensive, lack of radiation exposure, less time-consuming, easy, painless, and rarely requiring sedation. Usually, no preparation is required except in a few cases. It is also the preferred imaging tool for evaluating the surgical and non-surgical causes of acute abdomen in children. Ultrasound is also the preferred screening method for children suspected of having intra-abdominal mass. Aim and Objective: The present study is undertaken: (1) To identify specific causes of non-traumatic acute abdominal (NTA) pain in children; (2) to adopt the diagnostic efficacy of sonography as an initial tool for assessing those patients with probable clinical diagnosis; and (3) to triage patients for conservative or immediate surgery with available clinical diagnostic methods. Materials and Methods: A retrospective study of 100 pediatric patients aged between 1 and 14 years of both sexes with a history of non-traumatic acute abdomen attending outpatient services, in-patient, and emergency department at the Chamarajanagar Institute of Medical Sciences (CIMS) was conducted between March 2016 and March 2018 (for 2 years) for sonography. Results: Among 100 individuals, we had males followed by females (53%; 47%). The most common clinical symptoms of children with NTA were pain. Other symptoms included vomiting (66.7%; 15%), fever (68.5%; 31.6%), diarrhea (40%; 60%), cough (50%; 50%), and constipation (1%; 1%). The maximum number of cases in the group was >5 years–14 years. The most common sonography findings in this study were non-specific mesenteric lymphadenitis 49.4%, appendicitis (18.7%), intussusception, and cystitis (6.7%). followed by renal hydronephrosis (5.3%). Conclusion: Sonography, along with the associated clinical features, is a valuable adjuvant for a probable diagnosis. Other investigations such as laboratory findings, contrast-enhanced CT scan as indicated by the patient’s condition and requirement can be supported. This is particularly important in C-grade locations where other higher modes of investigation may not be available.

Appendicitis is the most common cause of acute abdomen. The diagnosis of appendicitis can be easy when it presents with the classical symptoms or is very challenging when present with atypical presentation. Around 20-30% of patients operated on for appendicitis have appendicolithiasis. Appendicolithiasis are usually small in size, and are called giant when more than 2cm in size. A 36 years old man was referred from a district hospital with a diagnosis of cecal cancer. His complaints were right lower quadrant (RLQ) abdominal mass of 03 months and pain of 18 months duration. Colonoscopy was normal but abdominal CT showed a RLQ mass with a dense radio-opaque shadow at its center. Giant appendicolith is a rare condition. A high index of suspicion and careful review of imaging findings is the key in early diagnosis and improved patient outcomes.

PurposeAbdominal fat necrosis is a rare cause of abdominal acute pain, classified into primary or secondary according to the cause. Primary fat necrosis includes epiploic appendagitis or idiopathic infarction of the greater omentum. This retrospective study focuses on multislice computed tomography (MSCT) findings and diagnosis of primary abdominal fat necrosis as a cause of acute abdomen.Material and methodsThis was a retrospective study with 20 patients included, presented to emergency room with acute abdominal pain diagnosed as primary fat necrosis. Retrospective evaluation was made of the patients’ clinical data, presentation, CT studies done at the acute stage, and their primary and final diagnosis.ResultsTwenty patients (eight male and 12 female, mean age 45 years, age range 20-70 years) diagnosed with abdominal fat necrosis (primary omental infarct) on CT imaging between October 2014 and June 2018 were evaluated. Clinically, five patients were suspected to be cholecystitis¸ eight patients as appendicitis, and four patients as diverticulitis. In addition, three patients had renal colic and were suspected to have ureteric stones; they showed suspected areas of abnormal fat density in non-contrast CT of the urinary tract. Idiopathic omental infarctions were detected in 13 patients on CT; all were on the right side. Laparoscopic excision was done for all. The other seven patients had epiploic appendagitis, seen on the left side, treated with conservative management.ConclusionsPrimary fat necrosis, although rare, can be presented as acute abdomen. MSCT is the main diagnostic tool for diagnosis of omental infraction and differentiation between other causes of acute abdomen.

The assessment of the financial performance of Islamic banking is mostly still measured by conventional measuring instruments. Where the measuring instrument only focuses on financial measurement while Islamic banking is a banking institution that is run using sharia principles, but does not ignore the financial side. The purpose of this study was to measure the financial performance of Islamic banking using the Sharia Conformity and Profitability (SCnP) method, which is a more complex performance measurement because it combines two inseparable assessment orientations, namely sharia and finance. This research is a descriptive quantitative research. The population in this study is the financial statements on sharia banking statistics published by OJK using saturated sampling as the sample of this study. The variables of this study are Sharia Conformity and Profitability. The types of data used are secondary data and the data collection technique in this study is documentation. The results of this study show the financial performance of Islamic banking, at the quadrant level showing SCnP results during the 2017-2021 period BUS in Indonesia are in four quadrants, namely the Lower Left Quadrant, which has sharia conformity and low profitability. Upper Left Quadrant, namely with low sharia compatibility and high profitability. Upper Right Quadrant, has sharia compatibility and high profitability. And the Lower Right Quadrant, where sharia conformity is high but the profitability is low. And the financial performance of UUS in Indonesia is in three quadrants, namely Lower Left Quadrant, Lower Right Quadrant and Upper Right Quadrant during the 2017-2021 period. Whereas in BPRS during the 2017-2021 period financial performance was in three quadrants namely Lower Left Quadrant Upper Left Quadrant and Lower Right Quadrant.

Paraduodenal hernias are congenital internal hernias that emerge as a result of the incomplete fusion of the mesentery with the peritoneum and abnormal intestinal rotation during the stages of foetal development. A rare cause of intestinal obstruction, especially in patients with a medical history free of abdominal operations, paraduodenal hernias account for approximately half of the cases of internal hernias and are responsible for 0.2–0.9% of intestinal obstructions. We hereby report the case of a 39-year-old female patient who presented with a three-hour episode of acute epigastric pain and nausea. Physical examination revealed tenderness and guarding at the palpation of the epigastrium and the left upper quadrant. Computed tomography was suggestive of an internal hernia at the level of the Treitz ligament. Emergency laparotomy was performed and the incarcerated jejunal loops were restored back to the abdominal cavity, while the defect at the root of the mesentery was suture closed, with care not to include the inferior mesenteric vein. The post-operative period was uneventful. Though rare, paraduodenal hernias should be included in the differential diagnosis in cases of acute abdomen or upper bowel obstruction, particularly in the absence of previous abdominal surgery. Surgical treatment is similar to that indicated for any other type of hernia, and involves reduction of the hernia’s contents and elimination of the defect.

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.

Introduction The neutrophil-to-lymphocyte ratio (NLR) has emerged in recent years as a predictor of inflammation in various infectious pathologies. Among them, its value in predicting severity or complications in acute appendicitis has been studied and validated in adults and children. Although these studies are clear about its usefulness, it’s still unclear what value is optimal as a cut-off point. However, there is a knowledge gap in whether this evidence can be extrapolated to pregnant women with acute appendicitis. Gestation is a physiological situation that causes an intrinsic alteration of the immune system, altering white blood cell counts, and making the pregnant woman vulnerable to infection. Among these, acute appendicitis is the most frequent cause of acute abdomen in pregnancy. The aim of this study is to analyse whether NLR can play a predictive role in the severity of acute appendicitis in pregnant women. Methods We reviewed medical records for all consecutive pregnant patients admitted for acute appendicitis from 2018 to 2023 in our tertiary care university hospital. Results Fourteen patients were analysed, mean age was 29 years. Five (35.7%) were in the first trimester, 4 in the second trimester and 5 in the third trimester. The mean evolution time from the onset of symptoms to diagnosis was 2.4 days. The most used diagnostic technique was abdominal ultrasound (13 cases) and only in one patient MRI was performed for diagnosis. Four appendectomies had an open approach, and the others were laparoscopic. During surgery, peritonitis was observed in 9 cases (64%), and in 4 of them there was generalized peritonitis. In 2 cases acute appendicitis triggered birth, both in the third trimester, and both presented peritonitis. The mean hospital stay was 4 days, and 11 patients (78.5%) received empirical antibiotic therapy after surgery. Of the 14 cases, 6 presented complicated acute appendicitis in the pathological study, which did not correlate with intraoperative findings. CPR was significantly elevated in cases with peritonitis (mean 163 mg/l in cases with peritonitis versus 52 mg/l in non-peritonitis). We found the same correlation between NLR and peritonitis, significantly higher with a mean of 15.84% in the peritonitis group versus 7.31% in cases without peritonitis, However, we did not find a correlation between the anatomopathological diagnosis and the NLR. Conclusions In 5 years, only 14 pregnant women presented acute appendicitis in our tertiary hospital, despite being the most common cause of acute abdomen during pregnancy. Due to the small sample we cannot draw conclusions, but we can observe trends. It seems that the NLR behaves similarly as a predictor of complication or severity, especially if there is peritonitis. In published literature, it seems that the average NLR in pregnant women is higher than that of the non-pregnant population. We also observed that more than half of appendicitis in pregnant women presented peritonitis, whether localized or generalized, which is higher than in the general population. It seems that the NLR may behave similarly in pregnant women with peritonitis as in the non-pregnant population, so it could help predict the presence of peritonitis to provide early care in this vulnerable population.

Adrenal infarction is an infrequent cause of severe abdominal pain during pregnancy. The magnetic resonance imaging (MRI) features of adrenal infarction have not previously been thoroughly described. A 20-year-old woman, gravida 1 para 0, presented at 27 4/7 weeks of gestation with sudden-onset right upper quadrant and flank pain. A 29-year-old woman, gravida 2 para 1, presented at 17 5/7 weeks of gestation with sudden-onset right abdominal and flank pain and again at 35 5/7 weeks of gestation with sudden-onset severe left flank and upper quadrant pain. In both patients, unilateral adrenal infarction was diagnosed on contrast-enhanced computed tomography after initial nondiagnostic ultrasonography and MRI. Clinical presentation and MRI features of nonhemorrhagic adrenal infarction are described. Nonhemorrhagic adrenal infarction may be an underdiagnosed cause of acute abdominal pain during pregnancy and can be diagnosed with MRI.

A cross sectional study on the pattern of lip prints was conducted among the population of Telangana region.A sample of 140 individuals comprising of 70 males and 70 females were taken from both medical andnursing students of the Mediciti Institute of Medical Sciences, Medchal, Telangana.The present study showed type-1 (vertical groove running across the lip) is the most common pattern presentin all the quadrants of the lip in both males and females. In the left upper quadrant, it is found to be 51.4%,followed by 37.1% in the left upper right quadrant, 49.3% in the lower left quadrant and 53.6% in the lowerright quadrant. Type-2 pattern (vertical partial length groove) is the second common pattern, in the upperleft quadrant, it is 37.1%, in the upper right 42.1%, in the lower-left 34.3% and lower right quadrant 27.9%.Type-3 (Branched groove) observed as the third common pattern in the study population, in the upper leftquadrant it is 11.4%, upper right 18.6%, lower left 15.7%, lower right quadrant 17.9%. Type-5 (Reticularpattern) is noticed in the upper right quadrant in 1.4%, lower left 0.7%, lower right 0.7% and not found inthe upper left quadrant. The type-6 pattern is found upper right quadrant in 0.7% of study population andType-4 pattern (intersected groove) is not found in our study group.Our study revealed that the pattern of lip prints for each individual in each quadrant is unique. Accordingto our study, there is no sex difference with lip print patterns. Study also revealed that there is no relationbetween lip print patterns and the blood groups, a near significant relation observed with the chi-square testin one quadrant, but not considered as significant.Lip print patterns are constant, do not change with time and the uniqueness of its nature in each individual,it can be used for personal identification in various medico-legal issues

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.

Hematemesis From Varices in a 14-year-old Without Hepatobiliary Disease: A "Wandering" Diagnosis.

Appendicitis is one of the most common causes of acute abdomen with life time risk between 6 and 8% and it’s a most common non obstetric surgical emergency during pregnancy. Appendicitis is claimed to be unknown in the villages of India and China in paper by A. M. Spencer. The reason is simply due to the fact that diagnostic facilities do not exist and cases are not recognized. So diagnosing acute appendicitis accurately and efficiently can reduce morbidity and mortality from perforation and other complications. Surgical intervention is the first choice for appendicitis with medical management being reserved for special situations.

Double parasite in appendicectomy specimen: Causal factor or incidental finding?