Uterine rupture mimicking Wunderlich’s syndrome in pregnancy: An unfortunate case

Introduction: Wunderlich’s syndrome (WS), characterized by non-traumatic renal haemorrhage into the subscapular and perinephric space is a rare entity in pregnancy. Aim: This article highlights the incidental discovery of a pregnant woman with WS that resulted in emergency nephrectomy. Case study: A 31-year-old gravida 4 para 3 female with 3 previous caesarean sections presented with acute abdomen and was in shock. The abdominal ultrasound revealed gross haemoperitoneum. With the preoperative diagnosis of a uterine rupture, surgical exploration was done showing an extensive right perinephric hematoma and active bleeding from the renal hilum. No renal tumor or pseudoaneurysm of the renal hilum was noted. Emergency nephrectomy was performed. Unfortunately, the foetus did not survive the ordeal. Results and discussion: WS occurs as a result of renal neoplasms, idiopathic causes, vascular diseases, infection, and miscellaneous. Ultrasonography can help to identify the perinephric hematoma, meanwhile, colour and/or spectral Doppler can aid in the detection of vascular pathologies. Contrast-enhanced computed tomography is still the imaging modality of choice. In pregnancy, a magnetic resonance imaging would be a better modality, avoiding radiation exposure to the foetus and consequent foetal malformations. Treatment includes arterial embolization and/or operative management such as nephrectomy. Conclusions: WS in pregnancy is a rare clinical entity requiring a high index of clinical suspicion for diagnosis. WS needs to be considered in pregnant patients presenting with shock with the presence of perinephric hematoma. A multidisciplinary approach is essential in providing optimum care

The great masquerader of pancreatic tuberculosis

Background: Pancreatic tuberculosis is a rare clinical entity. It represents a diagnostic challenge as the clinical presentation may mimic pancreatic malignancy. Case presentation: A 66-year-old gentleman presented with an incidental finding of a pancreatic tail mass on routine ultrasonography of the abdomen whilst working up on chronic kidney disease. He denied abdominal pain, fever, night sweats, constitutional symptoms or tuberculosis contact. On examination, there was no palpable mass per abdomen. The tumour marker of Ca 19-9 was normal. Ultrasonography revealed a lobulated heterogeneous hypovascular and hypoechoic mass at the tail of the pancreas. Contrast-enhanced computed tomography (CT) of the thorax and abdomen revealed a thickened right pleura, right pleural effusion with right lung collapsed consolidation and multiple mediastinal lymph nodes. There is an ill-defined hypodense mass seen in the tail and body of the pancreas measuring 3 × 7 × 3 cm with the presences of calcification within. The constellation of CT findings suggests a pancreatic malignancy with metastasis to the lungs. Endoscopic ultrasonography (EUS) assessment showed an irregular hypoechoic mass measuring 3.0 × 2.7 cm at the tail of the pancreas. Multiple rounded hypoechoic lesions were also seen scattered within the body of the pancreas with multiple enlarged para-aortic lymph nodes. A fine-needle aspiration biopsy of the lesion was consistent with granulomatous inflammation. The diagnosis of disseminated tuberculosis was made. The patient was subsequently started on antitubercular medication and recovered well. Conclusion: A high index of suspicion is needed to diagnose pancreatic tuberculosis, especially in patients whose radiological imaging shows a pancreatic mass with necrotic peripancreatic lymphadenopathy in endemic countries. EUS-guided fine-needle aspiration is the diagnostic modality of choice, and vigorous attempts should be made at obtaining a preoperative histological or bacteriological diagnosis to avoid unnecessary surgery

Choledochal cyst and aberrant biliary configuration along with situs inversus totalis: A case report

Situs inversus totalis is the complete transpositioning of thoracoabdominal viscera into a mirror image of the normal configuration. Choledochal cyst is the congenital cystic dilation of the biliary tract. Both these conditions coexisting in a patient is extremely rare. We hereby present a case of type IC choledochal cyst in a patient with situs inversus totalis presenting with biliary sepsis secondary to choledocholithiasis. Also detailed are the management and operative strategies employed to deal with this rare entity

The ChoCO-W prospective observational global study: Does COVID-19 increase gangrenous cholecystitis?

BACKGROUND: The incidence of the highly morbid and potentially lethal gangrenous cholecystitis was reportedly increased during the COVID-19 pandemic. The aim of the ChoCO-W study was to compare the clinical findings and outcomes of acute cholecystitis in patients who had COVID-19 disease with those who did not. METHODS: Data were prospectively collected over 6 months (October 1, 2020, to April 30, 2021) with 1-month follow-up. In October 2020, Delta variant of SARS CoV-2 was isolated for the first time. Demographic and clinical data were analyzed and reported according to the STROBE guidelines. Baseline characteristics and clinical outcomes of patients who had COVID-19 were compared with those who did not. RESULTS: A total of 2893 patients, from 42 countries, 218 centers, involved, with a median age of 61.3 (SD: 17.39) years were prospectively enrolled in this study; 1481 (51%) patients were males. One hundred and eighty (6.9%) patients were COVID-19 positive, while 2412 (93.1%) were negative. Concomitant preexisting diseases including cardiovascular diseases (p < 0.0001), diabetes (p < 0.0001), and severe chronic obstructive airway disease (p = 0.005) were significantly more frequent in the COVID-19 group. Markers of sepsis severity including ARDS (p < 0.0001), PIPAS score (p < 0.0001), WSES sepsis score (p < 0.0001), qSOFA (p < 0.0001), and Tokyo classification of severity of acute cholecystitis (p < 0.0001) were significantly higher in the COVID-19 group. The COVID-19 group had significantly higher postoperative complications (32.2% compared with 11.7%, p < 0.0001), longer mean hospital stay (13.21 compared with 6.51 days, p < 0.0001), and mortality rate (13.4% compared with 1.7%, p < 0.0001). The incidence of gangrenous cholecystitis was doubled in the COVID-19 group (40.7% compared with 22.3%). The mean wall thickness of the gallbladder was significantly higher in the COVID-19 group [6.32 (SD: 2.44) mm compared with 5.4 (SD: 3.45) mm; p < 0.0001]. CONCLUSIONS: The incidence of gangrenous cholecystitis is higher in COVID patients compared with non-COVID patients admitted to the emergency department with acute cholecystitis. Gangrenous cholecystitis in COVID patients is associated with high-grade Clavien-Dindo postoperative complications, longer hospital stay and higher mortality rate. The open cholecystectomy rate is higher in COVID compared with non -COVID patients. It is recommended to delay the surgical treatment in COVID patients, when it is possible, to decrease morbidity and mortality rates. COVID-19 infection and gangrenous cholecystistis are not absolute contraindications to perform laparoscopic cholecystectomy, in a case by case evaluation, in expert hands