Ileum perforation due to accidental chicken bone ingestion a rare cause of the acute abdomen

Ingestion of foreign bodies is not an uncommon occurrence, but most of them will pass through the gastrointestinal tract without consequences. Complication such as perforation is rare. We present a case of small bowel perforation secondary to the accidental ingestion of a chicken bone. The patient presented with abdominal pain, constipation and vomiting. Clinical examination confirmed generalized abdominal tenderness and rebound tenderness. Abdominal radiography showed multiple dilated loops of small bowel, and abdominal ultrasound (US) showed inflammatory changes on small bowel loops, with free fluid and fluid collection around intestinal loops. The patient underwent an emergency laparotomy. Intra operative findings revealed diffuse fibro purulent peritonitis with abscess between central small bowels loops. At about 60 cm from Bauchini valve we found a perforation of ileum at the anti-mesenteric site caused by a sharp chicken wishbone. The patient was treated with resection of the ileum segment (10 cm) and primary end-to-end anastomosis. Even that intestinal perforation by a foreign body is rare, physicians should consider possibility of intestinal perforation by a foreign body in the differential diagnosis of acute abdomen in patients presenting with abdominal pain

Antimicrobials: a global alliance for optimizing their rational use in intra-abdominal infections (AGORA)

Intra-abdominal infections (IAI) are an important cause of morbidity and are frequently associated with poor prognosis, particularly in high-risk patients. The cornerstones in the management of complicated IAIs are timely effective source control with appropriate antimicrobial therapy. Empiric antimicrobial therapy is important in the management of intra-abdominal infections and must be broad enough to cover all likely organisms because inappropriate initial antimicrobial therapy is associated with poor patient outcomes and the development of bacterial resistance. The overuse of antimicrobials is widely accepted as a major driver of some emerging infections (such as C. difficile), the selection of resistant pathogens in individual patients, and for the continued development of antimicrobial resistance globally. The growing emergence of multi-drug resistant organisms and the limited development of new agents available to counteract them have caused an impending crisis with alarming implications, especially with regards to Gram-negative bacteria. An international task force from 79 different countries has joined this project by sharing a document on the rational use of antimicrobials for patients with IAIs. The project has been termed AGORA (Antimicrobials: A Global Alliance for Optimizing their Rational Use in Intra-Abdominal Infections). The authors hope that AGORA, involving many of the worlds leading experts, can actively raise awareness in health workers and can improve prescribing behavior in treating IAIs

Utjecaj intraabdominalnog tlaka na osnovne vitalne funkcije i ishod liječenja

The purpose of the study was to point to the importance of measuring intra-abdominal pressure (IAP) and of early recognition of the consequences of increased IAP on basic vital functions. Measurement of IAP via urinary bladder was conducted every 12 hours in 70 surgical patients with acute abdominal syndromes not previously operated on. Based on the measured IAP values, all patients were divided into groups of patients with normal IAP values (n=20) and patients with increased IAP values (n=50) . Vital functions and basic laboratory analysis were monitored and the values obtained were compared with IAP in both patient groups. A statistically significant difference was found in body weight, body mass index, urine output, creatinine, urea, heart rate, partial pressure of oxygen (PaO2) and partial pressure of carbon dioxide (PaCO2) between patients with normal and increased IAP values. The increase in IAP values was found to be associated with an increase in PaCO2, respiratory rate, peak inspiratory pressure, central venous pressure, heart rate, Acute Physiology, Age and Chronic Health Evaluation II score, mortality rate, creatinine and urea values, and number of days of treatment in the intensive care unit. At the same time, the values of PaO2, blood oxygen saturation, diuresis and abdominal perfusion pressure were declining. IAP measurement is an old, cost-effective, reliable technique that is easy to perform and should be applied in all high risk patients.Cilj studije bio je ukazati na značenje mjerenja intraabdominalnog tlaka (intra-abdominal pressure, IAP) i ranog prepoznavanja promjena osnovnih vitalnih funkcija, koje su posljedica povećanja IAP. Mjerenje IAP je provedeno kroz mokraćni mjehur svakih 12 sati kod 70 bolesnika s akutnim abdominalnim sindromom koji nisu prethodno operirani. Na osnovi izmjerenih vrijednosti IAP bolesnici su podijeljeni u skupinu s normalnim vrijednostima IAP (n=20) i skupinu s povećanim vrijednostima (n=50). Praćenjem osnovnih vitalnih funkcija i laboratorijskih analiza dobivene vrijednosti uspoređivane su u odnosu na IAP u objema skupinama bolesnika. Statistički značajna razlika između bolesnika s normalnim i onih s povišenim IAP utvrđena je za tjelesnu težinu, indeks tjelesne mase, diurezu, vrijednosti kreatinina, ureju, srčanu frekvenciju, parcijalni tlak kisika (PaO2) i parcijalni tlak ugljičnog dioksida (PaCO2). Također je zapaženo da su s porastom IAP rasle i vrijednosti PaCO2, broja respiracija, vršnog inspiracijskog tlaka, centralnog venskog tlaka, srčane frekvencije, akutna fi zio loška, starosna i kronična evaluacija zdravlja II (Acute Physiology, Age and Chronic Health Evaluation, APACHE), stopa smrtnosti, vrijednosti ureje i kreatinina te broj dana liječenja u jedinici intenzivnog liječenja, dok su vrijednosti PaO2, zasićenje hemoglobina kisikom, diureza i abdominalni perfuzijski tlak bili u opadanju. Mjerenje intraabdominalnog tlaka je stara, jeftina, pouzdana metoda, jednostavna za izvođenje kod svih visoko rizičnih bolesnika

Altered cytokine expression in Helicobacter pylori infected patients with bleeding duodenal ulcer

Objective Peptic ulcer disease is a condition in which an important role has infection with H. pylori. The most common complication of peptic ulcer is bleeding. The presence of H. pylori triggers local and systemic cytokine signaling which may affect processes such as healing, gastric or duodenal rupture, and carcinogenesis. In this study, we examined the concentrations of IL-1β, IL-6, IL-10, TNF, TGF-β and IL-17A in serum by enzyme immunoassay and their mRNA expressions in periulcer biopsies obtained from patients with bleeding peptic ulcer by means of real-time-PCR. Results We have shown that pro-inflammatory IL-6 and TNF concentrations in serum were significantly higher in patients who were infected with H. pylori, while the concentrations of TGF-β and IL-17A were significantly lower compared to non-infected subjects. IL-17A expression in periulcer mucosa was significantly higher in patients who were infected with H. pylori, while the expression of other cytokines, there was no significant difference compared to non-infected controls. Considering higher serum concentrations in non-infected subjects and higher IL-17A expression in mucosal tissue of infected patients, our data support the studies that found IL-17A has protective role in eradication of H. pylori infection in infected patients

Intra-abdominal infection and acute abdomen-epidemiology, diagnosis and general principles of surgical management

Intra-abdominal infections are multifactorial and present an complex inflammatory response of the peritoneum to microorganisms followed by exudation in the abdominal cavity and systemic response Despite advances in management and critical care of patients with acute generalized peritonitis due to hollow viscus perforation, prognosis is still very poor, with high mortality rate. Early detection and adequate treatment is essential to minimize complications in the patient with acute abdomen. Prognostic evaluation of complicated IAI by modern scoring systems is important to assess the severity and the prognosis of the disease. Control of the septic source can be achieved either by nonoperative or operative means. Nonoperative interventional procedures include percutaneous drainages of abscesses. The management of primary peritonitis is non-surgical and antibiotic- treatment. The management of secondary peritonitis include surgery to control the source of infection, removal of toxins, bacteria, and necrotic tissue, antibiotic therapy, supportive therapy and nutrition. "Source control" is sine qua non of success and adequate surgical procedure involves closure or resection of any openings into the gastrointestinal tract, resection of inflamed tissue and drainage of all abdominal and pelivic collections

INTRA-ABDOMINAL INFECTION AND ACUTE ABDOMEN-EPIDEMIOLOGY, DIAGNOSIS AND GENERAL PRINCIPLES OF SURGICAL MANAGEMENT

Intra-abdominal infections are multifactorial and present an complex inflammatory response of the peritoneum to microorganisms followed by exudation in the abdominal cavity and systemic response Despite advances in management and critical care of patients with acute generalized peritonitis due to hollow viscus perforation, prognosis is still very poor, with high mortality rate. Early detection and adequate treatment is essential to minimize complications in the patient with acute abdomen. Prognostic evaluation of complicated IAI by modern scoring systems is important to assess the severity and the prognosis of the disease. Control of the septic source can be achieved either by nonoperative or operative means. Nonoperative interventional procedures include percutaneous drainages of abscesses. The management of primary peritonitis is non-surgical and antibiotic- treatment. The management of secondary peritonitis include surgery to control the source of infection, removal of toxins, bacteria, and necrotic tissue, antibiotic therapy, supportive therapy and nutrition. "Source control" is sine qua non of success and adequate surgical procedure involves closure or resection of any openings into the gastrointestinal tract, resection of inflamed tissue and drainage of all abdominal and pelivic collections

Functional liver anatomy: Surgical impact

The liver is a vital gland with a wide range of functions and complex anatomy. Liver anatomy can be described using different aspects: morphological anatomy and functional anatomy and now, the real anatomy, when ultrasound allows a precise intraoperative display in individual cases. The traditional morphological anatomy is based on the external appearance of the liver and does not show the internal features of vessels and biliary ducts branching which are of obvious importance in hepatic surgery. Functionally the liver is divided into eight functionally independent segments, each segment has its own vascular inflow, outflow and biliary drainage. This description, initiated by J. Cantlie in 1898, was followed by works of J. Healey and P. Schroy, N. Goldsmith and R. Woodburne, C. Couinaud, and H. Bismuth. In 1998. Federative Committee on Anatomical Terminology (FCAT) suggested using the liver Couinaud's classification. In 2000, International Hepato-Pancreato-Biliary Association (IHPBA) in Brisbane presented their recommendations of terminology of liver anatomy and liver resections. A single, worldwide-accepted classification of the liver still does not exist, however progress in the study of functional anatomy of the liver is a powerful impulse for development of modern liver surgery

Biomass gasification with preheated air: Energy and exergy analysis

Due to the irreversibilities that occur during biomass gasification, gasifiers are usually the least efficient units in the systems for production of heat, electricity, or other biofuels. Internal thermal energy exchange is responsible for a part of these irreversibilities and can be reduced by the use of preheated air as a gasifying medium. The focus of the paper is biomass gasification in the whole range ofgasification temperatures by the use of air preheated with product gas sensible heat. The energetic and exergetic analyses are carried with a typical ash-free biomass feed represented by CH 1.4O 0.59N 0.0017 at 1 ond 10 bar pressure. The toolfor the analyses is already validated model extended with a heat exchanger model. For every 200 K of air preheating, the average decrease of the amount of air required for complete biomass gasification is 1.3% of the amount requiredfor its stoichiometric combustion. The air preheated to the gasification temperature on the average increases the lower heating value of the product gas by 13.6%, as well as energetic and exergetic efficiencies of the process. The optimal air preheating temperature is the one that causes gasification to take place at the point where all carbon is consumed. It exists only if the amount ofpreheated air is less than the amount ofair at ambient temperature required for complete gasification at a given pressure. Exergy losses in the heat exchanger, where the product gas preheats air could be reduced by two-stage preheating

Solid-cystic-pseudopapillarytumor of the pancreas - case report

Solid-cystic-pseudopapillary tumor (SCPT) of the pancreas, described by Frantz (1959), is a very rare clinical pathologic entity with relatively low grade malignant potential. The tumor is more frequent in the body and tail of the pancreas. The majority of patients are young females. About 60% of patients are asymptomatic. Complications such as rupture, bleeding or secondary infections are rare. Metastases of the tumor and local recurrence after surgical treatment are also rare. Prognosis is excellent after complete surgical removal. It is difficult to make a preoperative diagnosis of pancreatic SCPT. The exact diagnosis is based on histological findings. Differential diagnosis should consider pancreatoblastoma, non neoplastic cysts, pancreatic pseudo-cysts and hydatid cyst. This is a case report of 39-year old woman who was admitted to our institution with abdominal discomfort and palpable abdominal mass in the upper abdomen. US and CT scan revealed round neoformation of 60 mm in diameter located in the body of the pancreas. Imaging features were not specific enough to allow for precise diagnosis. Curative R0 left spleno-hemipancreatectomy was performed. Histology of the resected specimen revealed solid and cystic-pseudopapillary tumor of the pancreas. The patient was discharged on postoperative day 7 in a good condition. The patient is well 48 months after the operation, with no impairment of pancreatic endocrine or exocrine function

Anatomic segment oriented hepatic resection in the management of colorectal metastases of the liver

The prime role of hepatic resection in the management of colorectal cancer metastatic to the liver is firmly established. At least a third of patients who undergo liver resection for colorectal metastases can expect to survive five years. Since 1999, 106 hepatic metastases were resected in 42 patients (synchr. 8, metachr. 34, pts). We performed 12 monosegmentectomies (S2-S8), 4 bisegmentectomies (S4b, S5 and S5, S6), 6 sectorectomies (right posterior, left paramedian, left lateral), 3 polysegmentectomies (S4b, S5 S6), 8 billateral sectionectomies (S2, S3 and S6,S7) and in 9 cases multiple segmentectomies. In 4 cases initially unresectable colorectal metastases were downstaged by transcatheter HAI regional chemotherapy (Implantofix) and after that successfully resected. We favour vascular inflow occlusion through selective division of appropriate portal pedicle at the porta hepatis or by transparenchymal approach. Median blood loss was330±160 ml. The complication rate ammounted to 9.52% (bile fistula, abscess collection). No method related lethality occurred. During the follow-up period we registered tumor recurrence rate of 19.1% (8 pts), of which two patients were subjected to liver re-resection. Overall 3-year survival rate (Kaplan-Meier) is 38.9%. Multivariate analysis shows a significant correlation between 3-year survival and solitary (p-0.031) and unilobar metastases (p-0.014)