Blunt abdominal injury resulting in a belly full of candy after a motocross accident, a case report

BackgroundBlunt traumatic gastric perforations in children are rare. Delayed diagnosis will lead to abdominal contamination and may result in morbidity and even mortality. We present a case of an adolescent who sustained blunt abdominal injury in a motocross accident and presented with remarkable hyperdense spherical shaped structures on the computed tomography (CT).Case presentationA 15-year-old boy arrived at the emergency room with an acute abdomen after a motocross accident. A CT scan of the abdomen demonstrated free air and hyperdense round structures in the stomach, pelvic cavity and right paracolic gutter. During emergency laparotomy a traumatic gastric perforation was sutured, a splenic rupture was treated with a vicryl mesh and multiple spherical food scraps were removed from the abdomen. After surgery, the boy clarified that he had eaten a whole bag of colorful and spherical shaped candy just before the accident.ConclusionsTraumatic gastric rupture in children is rare but physicians should be aware of this diagnosis in case of blunt abdominal trauma with free air on the CT scan. Gastric contents, in this case candy, can present as hyperdense shaped structures in the abdominal cavity on the CT scan

Primary umbilical endometriosis:a cause of a painful umbilical nodule

A female patient presented with a painful swelling in the umbilicus. Ultrasonography demonstrated a hypodense nodule of 1.8 cm. Surgical exploration revealed a subcutaneous, dark discoloured, lobulated swelling at the bottom of the umbilicus, which turned out to be primary umbilical endometriosis (PUE). Primary umbilical endometriosis is a rare and benign disorder, caused by the presence of ectopic endometrial tissue in the umbilicus, which can present as a painful, discoloured swelling in the umbilicus. The clinical distinction between primary umbilical endometrioses and other causes of an umbilical nodule is difficult. Additional imaging modalities do not show any pathognomonic signs for establishing this diagnose. Surgical exploration and excision are a safe and definitive treatment of primary umbilical endometrioses. This case highlights the importance of including PUE in the differential diagnosis of women with a painful umbilical nodule

Predictive value of a false-negative focused abdominal sonography for trauma (FAST) result in patients with confirmed traumatic abdominal injury

OBJECTIVE: To investigate if patients with confirmed traumatic abdominal injury and a false-negative focused abdominal sonography for trauma (FAST) examination have a more favorable prognosis than those with a true-positive FAST. METHODS: This study included 97 consecutive patients with confirmed traumatic abdominal injury (based on computed tomography [CT] and/or surgical findings) who underwent FAST. RESULTS: FAST was false-negative in 40 patients (41.2%) and true-positive in 57 patients (58.8%). Twenty-two patients (22.7%) had an unfavorable outcome (defined as the need for an interventional radiologic procedure, laparotomy, or death due to abdominal injury). Univariately, a false-negative FAST (odds ratio [OR] 0.24; p = 0.017) and a higher systolic blood pressure (OR, 0.97 per mmHg increase; p = 0.034) were significantly associated with a favorable outcome, whereas contrast extravasation on CT (OR, 7.17; p = 0.001) and shock index classification (OR, 1.89 for each higher class; p = 0.046) were significantly associated with an unfavorable outcome. Multivariately, only contrast extravasation on CT remained significantly associated with an unfavorable outcome (OR, 4.64; p = 0.016). When excluding contrast extravasation on CT from multivariate analysis, only a false-negative FAST result was predictive of a favorable outcome (OR, 0.28; p = 0.038). CONCLUSION: Trauma patients with confirmed abdominal injury and a false-negative FAST have a better outcome than those with a positive FAST. FAST may be valuable for risk stratification and prognostication in patients with a high suspicion of abdominal injury when CT has not been performed yet or when CT is not available

Reoperation after colorectal surgery is an independent predictor of the 1-year mortality rate

BACKGROUND: Comparative evaluation of surgical quality among hospitals must improve outcome and efficiency, and reduce medical costs. Reoperation after colorectal surgery is a consequence of surgical complications and therefore considered a quality-of-care indicator. With respect to the mortality rate, the 1-year mortality may be a more meaningful figure than in-hospital mortality, because it also reflects the impact of surgical complications beyond discharge. OBJECTIVE: The aim of our study was to evaluate the 1-year mortality after colorectal surgery and to identify predicting factors. DESIGN: This study was a retrospective analysis from our colorectal surgery database. PATIENTS: All patients who underwent elective colorectal surgery from 2005 to 2008 were included. MAIN OUTCOME MEASURES: Both univariate and multivariate analysis were performed to identify predicting factors. The following variables were analyzed: age, operative risk according to the ASA class, Charlson-Age Comorbidity Index, indication for and type of resection, primary anastomosis, tumor staging, anastomotic leakage, and reoperation. RESULTS: For 743 consecutive patients, the 1-year mortality rate was 6.9%. Patients were operated on mainly because of colorectal cancer (n = 537; 72%). The rate of reoperation and in-hospital mortality was 12.8% and 2.4%. Univariate survival analysis demonstrated that ASA class, age, Charlson-Age Comorbidity Index, reoperation, and stage of disease were independent predictors of 1-year mortality. Multivariate analysis showed that ASA class (P = .020; HR 1.69), age (P = .015; HR 2.08) and reoperation (P = .001; HR 2.72) are directly correlated with 1-year mortality. LIMITATIONS: Both patients with benign diseases and colorectal cancer are included. Furthermore, no clear guidelines on whether to perform a reoperation were available. CONCLUSION: One-year mortality after colorectal surgery is independently predicted by ASA class, age, and reoperation. Our results underline the value of the 1-year mortality rate and the reoperation rate as parameters for quality assessment in colorectal surgery

Molecular Imaging of Fever of Unknown Origin:An Update

18F-FDG PET/CT, 67Ga-citrate and white blood cell (WBC) scintigraphy are molecular imaging techniques currently used in the diagnostic workup of fever of unknown origin. However, it is unknown which technique fits which patient group best. A systematic literature search has been performed for original articles regarding the use of molecular imaging in fever of unknown origin. A total of 820 eligible studies were screened of which 63 articles evaluating 5094 patients met the inclusion criteria. 18F-FDG PET/CT provided good diagnostic accuracy (with a weighted mean sensitivity, specificity, positive predicting value, negative predictive value, accuracy and helpfulness of 84.4%, 61.8%, 80.7%, 67.8%, 76.3%, and 61.1%, respectively). Even within specific patient groups such as children, elderly, patients with connective tissue diseases, patients on renal replacement therapy, and HIV-infected patients, 18F-FDG PET/CT provided good diagnostic values. For 67Ga-citrate scintigraphy, the weighted mean sensitivity, specificity, positive predictive value, negative predictive value, and helpfulness were 42.2%, 80.3%, 82.4%, 41.9%, and 42.2%, respectively. WBC scintigraphy shows a weighted mean sensitivity, specificity, positive predictive value, negative predictive value and accuracy of 73.5%, 86.3%, 79.1%, 82.4%, and 79.5%, respectively. However, compared to 67Ga-citrate and WBC scintigraphy, significantly more research has been performed using 18F-FDG PET/CT and 18F-FDG PET/CT has the advantage of relatively short procedural duration; it is therefore the preferred molecular diagnostic imaging technique. 67Ga-citrate and WBC scintigraphy can only be considered if 18F-FDG PET/CT is not available

Guild medals from the Surgeons' Guild of Amsterdam

Between around 1620 and the end of the eighteenth century, every surgeon working in Amsterdam was presented with a guild medal on passing their surgeon's exams. These medals actually represented membership of the Surgeon's Guild of Amsterdam and could be used as proof of attendance at meetings of the Guild. From 1864 onwards surgeons also received the Hortus medal, which allowed them entry to the Hortus Medicus. Less common medals include medals for ensuring the surgeon's apprentices attended lectures, funeral medals for ensuring correct procedures regarding casket bearing duties were followed at a funeral, and medals of honour recognising services to the Guild. The collection of 17th and 18th century Amsterdam Surgeon's Guild medals numbers some 230 examples, and is the largest and most varied collection of its kind in the world. A few of the medals that have been preserved actually belonged to surgeons depicted in the famous series of group portraits. We examined who these surgeons were and what the purpose of these medals was. </p