Pelvic inflammatory disease is suspected, given the patient's symptoms. According to the 2006 SEGO protocol for Pelvic Inflammatory Disease, answer 2 is the false answer and, therefore, the one that should be marked. This is because hysterosalpingography can spread the infection to the pelvic and abdominal cavity. The rest of the answers are correct.

Pelvic inflammatory disease is suspected, given the patient's symptoms. According to the 2006 SEGO protocol for Pelvic Inflammatory Disease, answer 2 is [HIDDEN] and, therefore, the one that should be marked. This is because hysterosalpingography can spread the infection to the pelvic and abdominal cavity. The rest of the answers are [HIDDEN].

A 24-year-old woman consults for lower abdominal pain of two weeks of evolution that has worsened with the last sexual intercourse. She reports having a recent partner with whom she only occasionally uses a condom. On examination, she was in fair general condition. Temperature 38.6ºC, leukocytes 16,000/uL (85% neutrophils); CRP 30 mg/L. Speculum examination shows abundant abnormal vaginal discharge and painful cervical mobilization. Indicate the FALSE answer:

We would start antibiotic treatment as soon as we suspect the diagnosis.

We would indicate as a preferential complementary test a hysterosalpingography for tubal assessment.

Delay in diagnosis and treatment increases the occurrence of sequelae.

The presence of abscess would be a criterion for hospitalization.

[Pelvic inflammatory disease: contemporary diagnostic and therapeutic approach].

Pelvic inflammatory disease (PID) is polymicrobial infection in women characterized by inflammation of the upper genital tract, including endometritis, salpingitis, pelvic peritonitis, occasionally leading to the formation of tubo-ovarian abscess (TOA). PID primarily affects young, sexually active women, and it is highly correlated with having several sexual partners, intrauterine contraceptive device and sexually transmitted diseases. The spectrum of disease is caused most commonly by Chlamydia trachomatis and Neisseria gonorrhoeae in 30-50% of cases. PID is responsible for severe acute morbidity and significant long-term sequelae, including tubal factor infertility, ectopic pregnancy, and chronic pelvic pain. The following clinical features are suggestive of a diagnosis of PID: bilateral lower abdominal tenderness, abnormal vaginal or cervical discharge, fever (higher than 38 degrees C), abnormal vaginal bleeding, dyspareunia, cervical motion tenderness and adnexal tenderness, with or without a palpable mass. In laboratory findings, there is presence of excess leucocytes, elevated erythrocyte sedimentation rate or C-reactive protein. Transvaginal ultrasound scanning may be helpful, and its sensitivity is up to 85%. It can identify inflamed and dilated tubes and tubo-ovarian masses. Magnetic resonance imaging can be helpful in a final diagnosis in 95% of cases. In 15-30% of suspected cases, there is no laparoscopic evidence of disease. Treatment regimens for PID include broad-spectrum antibiotics, including coverage for Neisseria gonorrhoeae and Chlamydia trachomatis. The usage of parenteral or oral therapy, inpatient or outpatient regimens, depends on the patient's clinical condition. Considering the potential complications of disease, there is a need for good health educational programmes in reproductive period.

<i>Chlamydia</i> ascites: a call for sexually transmitted infection testing.

A 26-year-old gravida 2, para 2-0-0-2 woman with a recent uncomplicated vaginal delivery 10 weeks prior presented to our hospital with 5 weeks of abdominal swelling and discomfort. Four weeks after delivery, the patient began having right upper quadrant pain and was found to have cholelithiasis. She underwent an elective laparoscopic cholecystectomy 6 weeks prior to admission, but started to develop worsening abdominal swelling 1 week postoperatively. Abdominal distension and shifting dullness were present on examination. CT of the abdomen and pelvis was remarkable for moderate-volume ascites and mild enhancement of the pelvic peritoneum. Paracentesis removed 2.46 L of ascites fluid with 76% lymphocytic predominance. Results for <iChlamydia trachomatis</i were positive in urine, cervical swab and ascitic fluid. Doxycycline was prescribed for a diagnosis of pelvic inflammatory disease exudative ascites. Since discharge, she has completed her antibiotic course and reports resolution of all symptoms without recurrence of ascites.

Pharmacology_Katzung

Camille E. Beauduy, PharmD, & Lisa G. Winston, MD motion tenderness is present. A first-catch urine specimen is obtained for chlamydia and gonorrhea nucleic acid amplifi-cation testing. A urine pregnancy test is also ordered as the patient reports she “missed her last period.” Pending these results, the decision is made to treat her presumptively for chlamydial cervicitis. What are two potential treatment options for her possible chlamydial infection? How does her potential pregnancy affect the treatment decision? A 22-year-old woman presents to her college medical clinic complaining of a 2-week history of vaginal discharge. She denies any fever or abdominal pain but does report vaginal bleeding after sexual intercourse. When questioned about her sexual activity, she reports having vaginal intercourse, at times unprotected, with two men in the last 6 months. A pelvic examination is performed and is positive for muco-purulent discharge from the endocervical canal. No cervical

First_Aid_Step2

factors include non-Caucasian ethnicity, douching, smoking, multiple sex partners, and prior STDs and/or PID. Presents with lower abdominal pain, fever and chills, menstrual disturbances, and a purulent cervical discharge. are also seen. Diagnosed by the presence of acute lower abdominal or pelvic pain plus one of the following: A WBC count > 10,000 has poor positive and negative predictive value for PID. Order a β-hCG and ultrasound to rule out pregnancy and to evaluate for the possibility of tubo-ovarian abscess. Ultrasound is a noninvasive means of diagnosing PID. Look for: Thickening or dilation of the fallopian tubes Fluid in the cul-de-sac Antibiotic treatment should not be delayed while awaiting culture results. All sexual partners should be examined and treated appropriately. Outpatient regimens: Regimen A: Of oxacin or levof oxacin × 14 days +/– metronidazole × 14 days.

Gynecology_Novak

Leukocytosis and elevated erythrocyte sedimentation rate (ESR), a nonspecific, although more sensitive, sign of inﬂammation, are found in patients with acute PID. Pregnancy test is usually negative because PID as co-existent intrauterine pregnancy (IUP) is rare. If the pregnancy test is positive, an infected or very inﬂamed ectopic pregnancy, or instrumented IUP or infected, incomplete abortion should be suspected. Appendicitis and diverticulitis can be mistaken for PID. Laparoscopy can be useful if the diagnosis is uncertain. The Centers for Disease Control and Prevention guidelines for diagnosing PID state that PID should be suspected and treatment started if the patient is at risk for PID and she has uterine, cervical, or adnexal motion tenderness without any apparent cause (19a). Findings that support the diagnosis include cervical or vaginal mucopurulent discharge, elevated ESR or C-reactive protein (CRP), laboratory confirmation of gonorrhea or chlamydia, oral temperature of

Gynecology_Novak

facultative bacteria, anaerobes, and streptococci (16,40). Recommended regimens for the treatment of PID are listed in Table 18.5. An outpatient regimen of cefoxitin and doxycycline is as effective as an inpatient parenteral regimen of the same antimicrobials (41). Therefore, hospitalization is recommended only when the diagnosis is uncertain, pelvic abscess is suspected, clinical disease is severe, or compliance with an outpatient regimen is in question. Hospitalized patients can be considered for discharge when their fever has lysed (<99.5◦F for more than 24 hours), the white blood cell count has become normal, rebound tenderness is absent, and repeat examination shows marked amelioration of pelvic organ tenderness (42). Sexual partners of women with PID should be evaluated and treated for urethral infection with chlamydia or gonorrhea (Table 18.3). One of these STDs usually is found in the male sexual partners of women with PID not associated with chlamydia or gonorrhea (43,44).

InternalMed_Harrison

Sexually Transmitted Infections: Overview and Clinical Approach 878 impractical. Most patients with acute PID have lower abdominal pain of <3 weeks’ duration, pelvic tenderness on bimanual pelvic examination, and evidence of lower genital tract infection (e.g., MPC). Approximately 60% of such patients have salpingitis at laparoscopy, and perhaps 10–20% have endometritis alone. Among the patients with these findings, a rectal temperature >38°C, a palpable adnexal mass, and elevation of the ESR to >15 mm/h also raise the probability of salpingitis, which has been found at laparoscopy in 68% of patients with one of these additional findings, 90% of patients with two, and 96% of patients with three. However, only 17% of all patients with laparoscopy-confirmed salpingitis have had all three additional findings. In a woman with pelvic pain and tenderness, increased numbers of PMNs (30 per 1000× microscopic field in strands of cervical mucus) or leukocytes outnumbering epithelial cells in

InternalMed_Harrison

additional findings. In a woman with pelvic pain and tenderness, increased numbers of PMNs (30 per 1000× microscopic field in strands of cervical mucus) or leukocytes outnumbering epithelial cells in vaginal fluid (in the absence of trichomonal vaginitis, which also produces PMNs in vaginal discharge) increase the predictive value of a clinical diagnosis of acute PID, as do onset with menses, history of recent abnormal menstrual bleeding, presence of an IUD, history of salpingitis, and sexual exposure to a male with urethritis. Appendicitis or another disorder of the gut is favored by the early onset of anorexia, nausea, or vomiting; the onset of pain later than day 14 of the menstrual cycle; or unilateral pain limited to the right or left lower quadrant. Whenever the diagnosis of PID is being considered, serum assays for human β-chorionic gonadotropin should be performed; these tests are usually positive with ectopic pregnancy. Ultrasonography and magnetic resonance imaging (MRI) can

Chlamydia

Chlamydia is known as the "silent epidemic", as at least 70% of genital C. trachomatis infections in women (and 50% in men) are asymptomatic at the time of diagnosis, and can linger for months or years before being discovered. Signs and symptoms may include abnormal vaginal bleeding or discharge, abdominal pain, painful sexual intercourse, fever, painful urination or the urge to urinate more often than usual (urinary urgency). For sexually active women who are not pregnant, screening is recommended in those under 25 and others at risk of infection. Risk factors include a history of chlamydial or other sexually transmitted infection, new or multiple sexual partners, and inconsistent condom use. Guidelines recommend all women attending for emergency contraceptive are offered chlamydia testing, with studies showing up to 9% of women aged <25 years had chlamydia.

[Catatonia de novo, report on a case: immediate vital prognosis and psychiatric prognosis in longer term].

We report on the case of a 20 year old woman with no previous psychiatric history, who displayed a first episode of catatonia with acute onset. Symptoms started plainly with sudden general impairment, intense asthenia, headache, abdominal pain and confusion. After 48 hours, the patient was first admitted to an emergency unit and transferred to an internal medicine ward afterwards. She kept confused. Her behaviour was bizarre with permanent swinging of pelvis, mannerism, answers off the point and increasingly poor. The general clinical examination was normal, except for the presence of a regular tachycardia (120 bpm). The paraclinical investigations also showed normal: biology, EEG, CT Scan, lumbar puncture. Confusion persisted. The patient remained stuporous, with fixed gazing and listening-like attitudes. She managed to eat and move with the help of nurses but remained bedridden. The neurological examination showed hypokinaesia, extended hypotonia, sweating, urinary incontinence, bilateral sharp reflexes with no Babinski's sign and an inexhaustible nasoorbicular reflex. The patient was mute and contrary, actively closed her eyes, but responded occasionally to simple instructions. For short moments, she suddenly engaged in inappropriate behaviors (wandering around) while connecting back to her environment answering the telephone and talking to her parents. The patient's temperature rose twice in the first days but with no specific etiology found. During the first 8 days of hospitalization, an antipsychotic treatment was administered: haloperidol 10 mg per os daily and cyamemazine 37.5 mg i.m. daily. Despite these medications, the patient worsened and was transferred to our psychiatric unit in order to manage this catatonic picture with rapid onset for which no organic etiology was found. On admission, the patient was stuporous, immobile, unresponsive to any instruction, with catalepsy, maintenance of postures, severe negativism and refusal to eat. A first treatment by benzodiazepine (clorazepate 20 mg i.v.) did not lead to any improvement. The organic investigations were completed with cerebral MRI and the ruling out of a Wilson's disease. Convulsive therapy was then decided. It proved dramatically effective from the first attempt; 4 shocks were carried out before the patient's relatives ask for her discharge from hospital. The patient revealed she had experienced low delirium during her catatonic state. The clinical picture that followed showed retardation with anxiety. She was scared with fear both for the other patients and the nursing team. She kept distant and expressed few affects. The treatment at the time of discharge was olanzapine 10 mg per os. She was discharged with a diagnosis of catatonia but with no specific psychiatric etiological diagnosis associated. She discontinued her follow-up a few weeks later. After one year, we had no information about her. Catatonia has now become rare but remains a problem for clinicians. We reviewed data concerning short term vital prognosis and psychiatric long term prognosis in catatonia. Lethal catatonia is associated with acute onset, both marked psychomotor and neurovegetative symptoms. In the light of literature, there is no proband clinical criterion during the episode that is of relevant diagnostic value to ascertain the psychiatric etiology.

[Summary of the practice guideline 'Pelvic inflammatory disease' (first revision) from the Dutch College of General Practitioners].

The 1995 guideline on pelvic inflammatory disease (PID) has been updated. The general practitioner should consider PID whenever a woman of childbearing age complains of lower abdominal pain; the diagnosis should then be based on 5 criteria: (a) non-acute lower abdominal pain; (b) pain on upward movement or adnexal tenderness during vaginal touch; (c) painful or swollen adnexae; (d) ESR > or = 15 mm in the 1st hour or a temperature > 38 degree C, and (e) no indications for other diseases, such as appendicitis or an extra-uterine pregnancy. In case of diagnostic doubt, a gynaecologist must be consulted. Rapid treatment with antibiotics diminishes symptoms, shortens the course of disease, and may prevent complications such as infertility or extra-uterine pregnancy. Treatment should be started with ofloxacin and metronidazole. Due to the increasing antibiotic resistance of Neisseria gonorrhoeae, when there are indications for this pathogen the medicinal treatment should immediately be directed at it by means of cefotaxim, doxycycline and metronidazole. In his or her information to the patient, the general practitioner should devote attention to the major role of sexually transmissible micro-organisms and give advice, if necessary, regarding high-risk behaviour.

A postmenopausal women presenting with atypical symptoms and cervical cancer: a case report.

Globally cervical cancer kills millions of women every year. There is a wealth of evidence suggesting that cervical screening is one of the best defences against the development of cervical cancer. Lives could be saved if medical practitioners make a point of routinely enquiring about the date and result of the patient's last cervical smear test and if they repeatedly emphasize the importance of attendance for cervical smear tests, especially in post-menopausal women. A 66 year old caucasian woman presented with symptoms of a lower respiratory tract infection, weight loss, anorexia and night sweats. There was no history of post menopausal bleeding. She was admitted for intravenous antibiotics. A few days later she developed vomiting, abdominal pain and a brown vaginal discharge.She then had a CT scan which showed a pyometra extending to the umbilicus, with an intrauterine contraceptive device noted inside. After re-taking the history, it emerged that a Lippes loop was inserted 25 years previously. The patient was not given relevant information at the time and then unfortunately was lost to follow up.The pyometra was drained and the coil removed. However, at operation cervical cancer was suspected and biopsies taken. The patient's sepsis improved after pyometra drainage but histology subsequently confirmed stage 1B squamous cell cervical carcinoma. She was referred for a radical hysterectomy. Every consultation is an opportunity for health education and promotion. Patients need to be encouraged to utilize cervical screening programmes. It is also important to remember that cervical cancer can present with non-specific symptoms, thus the onus is on all doctors to take a good history and perform a thorough examination. Failing to do so may delay making the right diagnosis, with associated morbidity and mortality.

Acute odontogenic infection combined with crowned dens syndrome: a case report.

Calcium pyrophosphate dihydrate crystal deposition disease is a condition in which calcium pyrophosphate dihydrate crystal is deposited in joint cartilage and ligaments. Calcium pyrophosphate dihydrate crystal deposition disease that involves calcification around the odontoid process of the second cervical vertebra is called crowned dens syndrome. Crowned dens syndrome is accompanied by fever in addition to acute and intense neck, posterior head, and temporal pain; thus, distinguishing crowned dens syndrome may be difficult in the presence of odontogenic infection. To the best of our knowledge, this is the first report describing a patient with crowned dens syndrome with coexisting odontogenic infection. A 75-year-old Japanese woman was examined in the Emergency Department of this hospital due to a chief complaint of worsened buccal swelling on the left side. An odontogenic infection was considered, and she underwent her first examination. She presented with a body temperature of 37.4 °C, marked swelling and tenderness of her left lower eyelid through to her left cheek, and pain on the left temporal area. Blood tests revealed a leukocyte count of 6700/μL and a C-reactive protein level of 7.15 mg/dL. There was swelling and pain around the gingiva and acute purulent apical periodontitis of left maxillary second premolar. Cellulitis of the left cheek was diagnosed. After performing drainage of the pus, antibiotic treatment was initiated. Although her clinical symptoms improved, blood tests on day 9 of hospitalization revealed a leukocyte count of 6500/μL and a C-reactive protein level of 25.62 mg/dL, which were indicative of worsening symptoms. Computed tomography was performed to evaluate remote infection and images revealed a calcification around the odontoid process of her second cervical vertebra. When she was referred to the Orthopedic Surgery Department, pseudogout of the cervical spine was diagnosed. Subsequently, oral acetaminophen was initiated, and both her leukocyte count and C-reactive protein improved markedly. In the presence of persistent fever and abnormally high leukocyte and C-reactive protein indicative of an inflammatory reaction, coexistence of pseudogout should be considered. In particular, when symptoms of temporal pain are present, the possibility of pseudogout of the cervical spine must be considered in the differential diagnosis.

Emergency physicians' patterns of treatment for presumed gonorrhea and chlamydia in women: one center's practice.

No indicator reliably predicts if a woman has gonorrhea or chlamydia (sexually transmitted diseases [STDs]) during an Emergency Department (ED) visit. Before culture results return, emergency physicians (EPs) must choose whom to treat. We evaluated EP treatment of STDs within our institution. EPs voluntarily completed anonymous surveys while evaluating women requiring both a pelvic examination and STD cultures, except for sexual assault victims. The questionnaires asked for patients' demographics, history, physical examination, and in-ED laboratory tests, and whether any particular section of the encounter caused treatment. The treated and untreated groups' characteristics, as reported by the examining physicians, were compared. There were 145 questionnaires returned over a 6-month period; 41/145 patients (28%) were treated for presumed STD-28 (68%) based on physical examination, 8 (19.5%) on history, and 5 (12.5%) on in-ED laboratory tests. Comparison of treated vs. untreated groups revealed no difference in patient demographics. The treated group had more historical positives (3.92 vs. 2.84, respectively; p < 0.001) and physical examination findings (3.39 vs. 1.24, respectively; p < 0.001) compared to the untreated group. Eleven patients (7.58%) had positive STD cultures, 4 (9.75%) in the treated group and 7 (6.73%) in the untreated group (p > 0.05). In our institution, EPs chose to treat patients with more historical and physical examination findings, not based on demographics. Our EPs' presumptive STD treatment paradigms do not accurately distinguish patients with positive pelvic culture results from those with negative results, supporting the available literature that describes the difficulty of this diagnosis. Individual EDs must recognize this infection identification problem and, after assessment of their treatment population, institute either a liberal presumptive STD treatment regimen for all comers, or establish reliable and timely follow-up for women left untreated.

Identification of symptoms that indicate a pelvic examination is necessary to exclude PID in adolescent women.

Diagnosis of chlamydia, gonorrhea, and vaginitis is now possible in adolescents using urine testing and vaginal swabs obtained by care provider or patient. However, a complete pelvic examination is necessary to diagnose pelvic inflammatory disease (PID). It is thus important to identify patients who might have pelvic inflammatory disease to assure complete gynecologic assessment of genitourinary symptoms. To determine whether adolescent patients with pelvic inflammatory disease report predictable symptoms during the medical interview and to determine what proportion of patients diagnosed with PID report at least one predictor symptom.  Observational study. Hospital-based adolescent clinic and Job Corps health service. A convenience sample (n = 193) of adolescent and young adult women who had a pelvic examination performed to evaluate a wide range of genitourinary symptoms. Clinical diagnosis of pelvic inflammatory disease. Sensitivity, specificity, and positive and negative predictive value of predictor symptoms for identifying patients given a diagnosis of pelvic inflammatory disease. Twenty (10.4%) patients received a clinical diagnosis of PID. Lower abdominal pain was the most common symptom (90.0%) reported by these patients. All of the patients with PID reported either lower abdominal pain or dyspareunia in the medical history compared with 97 (56.1%) of those without PID. The presence of lower abdominal pain and/or dyspareunia in the clinical history yielded a sensitivity of 100%, specificity of 44%, and positive and negative predictive value of 17% and 100%, respectively, for identifying patients given a diagnosis of PID. This study identified two symptoms reported in the medical history (lower abdominal pain and dyspareunia) that were associated with a clinical diagnosis of pelvic inflammatory disease. If lack of these two symptoms was used as a criterion for omitting a pelvic examination, more than one third of the patients in this study could have been evaluated for cervical and vaginal infections with urine and directly obtained vaginal swabs. Although some of these patients might have required a pelvic examination to exclude other causes of abnormal vaginal bleeding, at least 30% of the total sample could have been evaluated without a speculum and bimanual examination. If further studies support these findings, patients with symptoms suggestive of uncomplicated genitourinary infection (e.g., vaginal discharge, vaginal pruritus, or dysuria) who deny lower abdominal pain and dyspareunia can be evaluated with urine and vaginal samples in place of a speculum and bimanual examination.

A Case of a False-Positive Urine Pregnancy Test and Delayed Diagnosis of Obstructive Pyelonephritis.

BACKGROUND Urine pregnancy tests are usually performed by women at home and also by healthcare professionals. However, there are several conditions that may cause a false-positive urine pregnancy test, including trophoblast tumors, malignancy, nephrotic syndrome, adenomyosis, tubo-ovarian abscess, and paraneoplastic syndromes. A case is presented of a false-positive urine pregnancy test in a 28-year-old woman with a history of tubal ligation, who had a delayed diagnosis of obstructive pyelonephritis due to renal calculus. CASE REPORT A 28-year-old woman had previously been sterilized by tubal ligation. She presented with acute pyelonephritis associated with a left staghorn renal calculus and was found to have a false-positive urine pregnancy test, which delayed the diagnosis and management of her acute pyelonephritis. On follow-up, she had a negative serum pregnancy test. Abdominal computed tomography (CT) identified a left-sided staghorn calculus resulting in partial ureteric obstruction and hydronephrosis. She was treated with antibiotics, including cefazoline, and a left nephrostomy tube was sited to treat her hydronephrosis. Her pain was initially managed with acetaminophen and hydrocodone. Four days after her initial hospital admission, the patient was stable enough to go home on oral levofloxacin and pain medication. CONCLUSIONS This case of a false-positive urine pregnancy test in a 28-year-old woman with a history of tubal ligation highlights that this association may result in the delay in the diagnosis and treatment of acute pyelonephritis.

Diagnosis and treatment of acute salpingitis.

Acute salpingitis is one of the most common acute gynecologic diseases and occurs in approximately 750,000 women each year in the United States. Use of laparoscopy to confirm the diagnosis of acute salpingitis has shown that the signs and symptoms classically ascribed to this disease are not specific to it. Fever, leukocytosis, elevated ESR and adnexal masses or swelling are not necessary to make a diagnosis of acute salpingitis. Lower abdominal pain and adnexal tenderness are the most consistent findings. Microbiologic data obtained by laparoscopy and culdocentesis have raised questions about the role of N. gonorrhoeae in salpingitis and have demonstrated that, as in pelvic infections generally, acute salpingitis is associated with mixed aerobic-anaerobic bacterial flora. Good results in the treatment of acute salpingitis depend upon: (1) early diagnosis, (2) hospitalization and bed rest, (3) the use of antibiotic therapy that takes into account the polymicrobial etiology of acute salpingitis, (4) prevention of recurrent episodes of salpingitis through efforts at patient education and identification and treatment of sexual partners. Most important, we must remember that what is at stake is often the future reproductive potential of a young woman. It must be weighed against both patient and physician convenience and cost. Further investigative efforts are essential to determine the role of IUDs in pelvic infections, discover the true microbiologic etiology of salpingitis and establish appropriate antimicrobial treatment as determined by prospective, microbiologically controlled investigations.

Tubo-Ovarian Abscess -- History and Physical

A complete physical examination, including a thorough pelvic exam, must be performed. The speculum and bimanual exam should assess the consistency, size, and mobility of the uterus and both adnexa. [5] Mucopurulent discharge and cervical motion tenderness are indicative of PID, and concomitant uterine or adnexal tenderness should raise concern for a TOA. [5] A detailed abdominal examination and careful attention to vital signs will help determine associated acute abdomen or systemic inflammatory response syndrome (SIRS). [5] Routine blood work may demonstrate leukocytosis with a left shift and urine, cervical and blood cultures may show bacterial growth. [5] A wet mount of vaginal discharge may show clue cells. [5] A urine pregnancy test should be performed to rule out an intrauterine or ectopic pregnancy. [5]

Ectopic pregnancy following emergency contraception with ethinyloestradiol-levonorgestrel: a case report.

Emergency contraception with ethinyloestradiol-levonorgestrel is effective, and ectopic pregnancy following its failure is rare. A 21-year-old nulligravid Japanese woman with regular menstrual periods took ethinyloestradiol-levonorgestrel pills for emergency contraception (EC) 36 and 48 hours after a coitus complicated by retention of the condom in the vagina. She started bleeding vaginally 24 days after that intercourse. As the bleeding continued for three weeks she consulted a gynaecologist. The pregnancy test was positive. Two weeks later she complained of lower abdominal pain, and transvaginal ultrasonography suggested a pelvic blood collection. At emergency surgery, she was found to have a left tubal pregnancy. Although ectopic pregnancy after failure of EC is rare, one should be alert to its possible occurrence.

Gynecology_Novak

Evaluation of both vaginal and endocervical secretions is a crucial part of the workup of a patient with PID (38). In women with PID, an increased number of polymorphonuclear leukocytes may be detected in a wet mount of the vaginal secretions or in the mucopurulent discharge. More elaborate tests may be used in women with severe symptoms because an incorrect diagnosis may cause unnecessary morbidity (39) (Table 18.4). These tests include endometrial biopsy to confirm the presence of endometritis, ultrasound or radiologic tests to characterize a tubo-ovarian abscess, and laparoscopy to confirm salpingitis visually. Treatment Therapy regimens for PID must provide empirical, broad-spectrum coverage of likely pathogens, including N. gonorrhoeae, C. trachomatis, M. genitalium, gram-negative Table 18.4 Clinical Criteria for the Diagnosis of Pelvic Inﬂammatory Disease Additional criteria to increase the specificity of the diagnosis

Pneumonia

In children, low oxygen levels and lower chest indrawing are more sensitive than hearing chest crackles with a stethoscope or increased respiratory rate. Grunting and nasal flaring may be other useful signs in children less than five years old. Lack of wheezing is an indicator of Mycoplasma pneumoniae in children with pneumonia, but as an indicator it is not accurate enough to decide whether or not macrolide treatment should be used. The presence of chest pain in children with pneumonia doubles the probability of Mycoplasma pneumoniae. Diagnosis in adults In general, in adults, investigations are not needed in mild cases. There is a very low risk of pneumonia if all vital signs and auscultation are normal. C-reactive protein (CRP) may help support the diagnosis. For those with CRP less than 20 mg/L without convincing evidence of pneumonia, antibiotics are not recommended.

[Criteria of recovery from gonorrhea].

A total of 563 case histories of gonorrhea patients and 218 ones of patients with gonorrhea recurrences are analyzed. 86.7-87.5% of recurrences were recorded in the first week after treatment for acute or chronic condition (before the provocation test). The relapses develop earlier after the treatment for acute or subacute gonorrhea than for the chronic condition, and are most common between the third and seventh days after therapy. The share of patients timely consulting the doctors is in inverse proportion with the time of the check-ups (the criterion of cure being 96.2%, the first control 84.1%, the second one 62%). The validity of cure should better be checked up on the fifth-sixth days after therapy, and not on days 7-10. Patients with complicated urogenital diseases (prostatitis, orchiepididymitis, infiltrative urethritis) should be followed up after the first check-up.

Pelvic inflammatory disease

The disease is caused by bacteria that spread from the vagina and cervix. Infections by Neisseria gonorrhoeae or Chlamydia trachomatis are present in 75 to 90 percent of cases. Often, multiple different bacteria are involved. Without treatment, about 10 percent of those with a chlamydial infection and 40 percent of those with a gonorrhea infection will develop PID. Risk factors are generally similar to those of sexually transmitted infections and include a high number of sexual partners and drug use. Vaginal douching may also increase the risk. The diagnosis is typically based on the presenting signs and symptoms. It is recommended that the disease be considered in all women of childbearing age who have lower abdominal pain. A definitive diagnosis of PID is made by finding pus involving the fallopian tubes during surgery. Ultrasound may also be useful in diagnosis.

[A case of pulmonary tuberculosis in which diagnosis was delayed because of prior treatment with fluoroquinolone and metronidazole].

We report the case of a patient with pulmonary tuberculosis, whose diagnosis was delayed because of prior treatment with fluoroquinolone and metronidazole. A 35-year-old woman developed productive cough, fever, and back pain, which lasted for 3 weeks before admission to hospital. She had been diagnosed with lower respiratory infection and was treated with garenoxacin mesilate hydrate for 7 days before admission. As her symptoms did not improve, she was referred to our hospital for further evaluation. A chest computed tomography scan revealed confluent consolidation in the right lower lung, predominantly in segment 7, and lung abscess was initially suspected. Since chemotherapy with ceftriaxone and minomycin did not reduce her symptoms, metronidazole was added on day 4. Her symptoms improved dramatically and she was discharged on day 15. Metronidazole was given for a total of 3 weeks, and 2 weeks after discontinuation of metronidazole, she presented with recurrent chest pain and was diagnosed with active pulmonary tuberculosis. In addition to the atypical imaging findings in this patient, the use of chemotherapeutics such as garenoxacin mesilate hydrate and metronidazole, which have anti-tuberculosis effects, meant that the diagnosis of tuberculosis was complicated and hence delayed. We should keep in mind that some general chemotherapy agents, including linezolid, also have anti-tuberculosis effects and may cause similar problems with diagnosis.

Surgical considerations in the diagnosis and treatment of pelvic inflammatory disease.

Pelvic inflammatory disease continues to be a common finding in young women with lower abdominal pain. Typical emergency room pelvic inflammatory disease, with classic symptoms of pain, fever, and a history of high-risk sexual behavior, is easily diagnosed with a high degree of specificity. However, the majority of patients with pelvic inflammatory disease have atypical symptoms, and their condition may be incorrectly diagnosed and treated. Careful attention to the physical signs of pelvic infection and the evaluation of the vaginal secretions for leukocytes improves diagnostic accuracy. Liberal use of diagnostic laparoscopy to confirm the possibility of acute salpingitis is recommended in young women, who have much to lose from a case of untreated salpingitis. Outpatient treatment with a beta-lactam antibiotic followed by a course of doxycycline adequately treats patients with N. gonorrhoeae and C. trachomatis infections. However, patients with suspected anaerobic upper genital tract infection such as those infections associated with tubo-ovarian abscess or IUD use should be admitted for parenteral antibiotic therapy and observation. Laparotomy and extirpative surgery should be reserved for seriously ill patients with generalized peritonitis associated with rupture of a tubo-ovarian abscess and for patients who do not respond to antibiotic therapy. Sound judgment regarding the extent of extirpative surgery, taking into consideration the wishes of the patient with respect to future fertility and hormone production, will lead to an acceptable outcome.

Brucellar spondylo-discitis with rapidly progressive spinal epidural abscess presenting with sciatica.

Case report. To present a patient with spinal brucellosis, which was initially presented with sciatica and misdiagnosed as a lumbar disc herniation owing to nonspecific neurological and radiological findings. The delay in diagnosis led to rapid progression of the disease and complications. Department of Neurosurgery at a tertiary university teaching hospital (Sutcu Imam University Medical Center in Turkey). A 57-year-old woman with a history of low-back pain for 6 months, fatigue, and severe left-sided sciatica for the last 3 months presented to our hospital. Three months earlier, at another hospital, she had had a negative Rose-Bengal test for brucellosis and a lumbar computed tomography performed at that time showed only minimal L4-5 annular bulging. For 2 months, she was treated with analgesics for 'lumbar disc herniation' without relief of pain. On presentation to our department, her magnetic resonance imaging (MRI) examination showed edema and minimal annular bulging at L3-4 and L4-5. When her Rose-Bengal test returned positive, she was started on triple antibiotics for presumed Brucella infection. When symptoms and neurologic signs worsened while taking antibiotics, repeat MRI scan showed a spinal epidural abscess at the L4-5 level. Emergent surgery and 8 weeks of antibiotics resulted in cure. In areas endemic for brucellosis, subtle historical and exam features should be sought to exclude an infection such as brucellar sponylo-discitis. Appropriate serological tests should be readily available to confirm or exclude this diagnosis in selected patients, to avoid delays in antibiotic treatment.

PID: clinical and laparoscopic aspects.

Clinical signs of pelvic inflammatory disease (PID) are not constant and are often limited to slight pelvic pain. Laparoscopy can lead to a rapid and correct diagnosis of PID. Intrapelvic bacteriologic samples can be obtained so as to administer the proper antibiotic. The exact nature of the lesions can be evaluated, and in severe cases, recent abscesses can be treated with good results for fecundity. Because the results in cases of long-standing abscess are not so good, laparoscopy should be performed at the onset of infection and not be reserved until after some weeks of inefficient medical treatment, especially in young women who have not completed their family. In primary chronic salpingitis, the lack of any clinical signs usually leads to a delay in diagnosis until women consult for fertility problems. The ideal point would be to detect some biologic or clinical change that may lead to diagnosis such as a positive anti-Chlamydia trachomatis (CT) serology or, in the future, positive anti-CT Hsp 60 antibody could be the key to detecting and treating silent salpingitis in young women, CT being the main microorganism involved in chronic salpingitis. Screening for C. trachomatis low genital tract infection is mandatory in young people in order to control the epidemic.

Early Gestational Age Placenta Accreta Case Report: Can We Avoid Missed Diagnosis?

BACKGROUND Placenta accreta is an abnormal invasive placenta that can be life-threatening because of the risk of hemorrhage. Its incidence has increased due to high cesarean delivery rates. Early gestational age placenta accreta is difficult to diagnose and misdiagnosis can lead to inappropriate treatment. CASE REPORT Patient 1, a 34-year-old woman (para 2 abortus 1) with 2 previous cesarean deliveries, was referred to our department for vaginal bleeding and abdominal pain. She received 2 curettages for blighted ovum; then, ultrasound examination found uterus perforation and fluid in the Douglas cavity. Exploratory laparotomy confirmed uterine perforation, and a hysterectomy was performed. Histopathological examination revealed placenta accreta. Patient 2, a 35-year-old woman (para 3) with 3 previous cesarean deliveries, was treated at a previous hospital for vaginal bleeding and stomach enlargement. She received serial chemotherapy for gestational trophoblastic neoplasia. Ultrasound examination showed a nonhomogeneous opacity in the lower uterine corpus with color score 4. Total abdominal hysterectomy was performed, and histopathological examination revealed placenta accreta. Patient 3, a 32-year-old woman (para 2) with 2 previous cesarean deliveries, had irregular vaginal bleeding suspected as gestational trophoblastic neoplasia due to ultrasound examination and positive beta-human chorionic gonadotropin. Ultrasound and MRI examination showed enlargement with nonhomogeneous opacity, color score 4, and bridging vessels. Due to our previous experience, we suspected it was a placenta accreta and performed a hysterectomy. The histopathology result indicated placenta accreta. CONCLUSIONS The key point in diagnosing placenta accreta properly is to evaluate the morphometric changes based on the structure using imaging like ultrasound. Collection and analysis of these data enables precise diagnosis in early gestational age placenta accreta.

[The salpingitis diagnosis under scrutiny].

The rationale for the diagnosis of Pelvic Inflammatory Disease (PID) was studied among hospitalized patients at the Department of Gynaecology, Regional Hospital of Trondheim, Trondheim. From 1 January 1991 to 31 December 1993, 153 patients were discharged with a diagnosis of Pelvic Inflammatory Disease. In retrospect, the diagnoses were reconsidered applying strict criteria. All 26 patients (17%) who had a diagnosis verified by laparoscopy were classified as suffering from a "true" diagnosis, 83 (54%) patients were reconsidered as suffering from a "more likely" and 44 (29% as suffering from a "less likely" diagnosis of Pelvic Inflammatory Disease. Women who had a laparoscopy verified diagnosis of Pelvic Inflammatory Disease, had higher ESR (erythrocyte sedimentation rate), C-reactive protein and temperature when compared with women reclassified as "less likely" suffering from Pelvic Inflammatory Disease. Only 72% of the patients had microbiological sampling from the cervix. In order to increase diagnostic precision we argue for minimum criteria and a systematic clinical examination, including vaginal ultrasound, when diagnosing Pelvic Inflammatory Disease. We recommend more diagnostic use of laparoscopy especially among women with mild symptoms and few objective signs.

Vaginal atresia

Diagnosis Vaginal atresia can sometimes be diagnosed by physical examination soon after birth. A child with vaginal atresia often has other congenital abnormalities and other tests such as X-ray and tests to evaluate the kidneys are done. Findings in adolescents may include abdominal pain, difficulty voiding, and backache, but most present with amenorrhea. Difficulties with sexual intercourse can suggest atresia. In the event that the condition is not caught shortly after birth, vaginal atresia becomes more evident when no menstrual cycle is occurs. If vaginal atresia is suspected by the doctor, a blood test may also be request for any of the previously mentioned syndromes, a magnetic resonance imaging (MRI) test, or an ultrasound. A regular evaluation of children born with an imperforate anus or anorectal malformation should be paired with the assessment of the results from these tests.

Diagnosing PID--getting the balance right.

The objective of the study was to determine the clinical manifestations and diagnostic criteria used to diagnose presumptive pelvic inflammatory disease (PID) at the Sydney Sexual Health Centre (SSHC). The study was a retrospective, case-note review of all women diagnosed with presumptive PID between April 1991 and December 1997. Seven hundred and thirteen women were included. The commonest recorded symptoms were vaginal discharge (68%), lower abdominal pain (65%) and dyspareunia (57%), while adnexal tenderness (83%), cervical motion tenderness (75%) and cervicitis (56%) were the most frequently recorded examination findings. Sixty-two per cent were prescribed doxycycline and metronidazole. The recording of signs and symptoms in women with presumptive PID was poor and only 22% met the current Centers for Disease Control (CDC) diagnostic criteria. It is likely that PID is over diagnosed in this group of women. This may lead to under diagnosis of other conditions causing pelvic pain and may be detrimental to reproductive health.

Case 283.

History A 44-year-old woman who was a resident of Bihar, which is a state in eastern India, presented to the surgical outpatient department of our hospital with a history of gradually increasing swelling of the right breast associated with redness, pain, and itching over the past month (Fig 1). She reported a general sense of malaise and experienced episodes of chills over the past 6 months; however, she had no documented fever. There was no history of breast trauma. No history suggestive of a possible hypercoagulable state could be elicited (she was a nonsmoker, had undergone uncomplicated normal vaginal delivery 15 years earlier, was not taking oral contraceptives, and had no history to suggest past deep venous thrombosis). General physical examination findings were unremarkable. On local examination, she was found to have diffuse enlargement of the right breast. The skin over the lateral part of the breast was erythematous and showed the presence of prominent superficial veins. On palpation, few ill-defined firm mobile masses were found in the upper outer quadrant with overlying skin induration. No skin ulceration or nipple discharge was present. Few firm and discrete lymph nodes were palpable in the right axilla. Laboratory investigations showed mild anemia (hemoglobin level, 10 g/dL; normal range, 12-15 g/dL), a total leukocyte count of 14 000 cells per microliter (14 cells × 10<sup9</sup/L) (normal range, 4500-11 000 cells per microliter [4.5-11 cells × 10<sup9</sup/L]), a normal differential leukocyte count (74% neutrophils [normal range, 40%-80%], 24% lymphocytes [normal range, 20%-40%], and 2% eosinophils [normal range, 1%-4%]), and an erythrocyte sedimentation rate of 31 mm per hour (normal range, 0-29 mm per hour). She underwent both mammography (Fig 2) and US (Fig 3). Real-time US showed mobile structures on the series of US images obtained seconds apart (Fig 4). On the basis of the imaging findings, US-guided fine-needle aspiration cytology was performed to confirm the diagnosis, and appropriate treatment was instituted.


This is a typical description of a picture of intestinal obstruction due to bridging or adhesions due to previous surgery. The correct answer is 5 and not 1 because most of these situations resolve spontaneously with conservative treatment.

This is a typical description of a picture of intestinal obstruction due to bridging or adhesions due to previous surgery. The [HIDDEN] and not 1 because most of these situations resolve spontaneously with conservative treatment.

55-year-old woman, operated on for appendicitis 24 years ago, who comes in because while previously well, she has started with repeated vomiting after breakfast, about 12 hours ago, associated with abdominal distention. She presented a diarrhea stool a few hours after the onset of the symptoms. Examination revealed abdominal distension, tympanism and increased bowel sounds, but no peritoneal irritation. Laboratory tests showed no abnormalities. The abdominal X-ray showed dilatation of the small bowel loops, without gas in the rectal ampulla. Regarding this case it is true that:

This is a picture of intestinal flange obstruction requiring emergency laparotomy.

Most likely we are facing a case of obstruction at the level of the large intestine.

The fact that the patient presented a diarrheal stool allows us to exclude the diagnosis of intestinal obstruction. Further imaging studies are necessary to ensure a diagnosis.

We should indicate the practice of a decompressive colonoscopy.

Initial management should be conservative, with serum therapy, nasogastric aspiration and periodic clinical, analytical and radiographic monitoring.

Intestinal obstruction and ischemia by necrotic annular Meckel's diverticulum: Case report and review of the literature.

Meckel's diverticulum (MD) is a vestigial remnant of the omphalomesenteric duct, representing the most common congenital malformation of the gastrointestinal tract. Diagnosis of MD is a challenge because of its rarity and frequent asymptomaticity. Radiological exams generally aren't useful for its diagnosis. Intestinal obstruction represents the most common complication of MD in adults. Surgery is the appropriate treatment of complicated MD. A 70-year-old Caucasian male was admitted to the Emergency Department with a two-day history of abdominal pain associated with inability to pass gas or stool, nausea and vomiting. Physical examination revealed abdominal distention and abdominal pain without Blumberg's sign. Abdominal contrast-enhanced computed tomography (CECT) showed small bowel obstruction caused by suspected MD. Laboratory tests reported high serum levels of glycemia, LDH, C-reactive protein and leukocytosis. After diagnosis of intestinal obstruction, the patient underwent exploratory laparotomy: a segmental resection of ischemic distal ileum bearing a necrotic MD was performed. The postoperative course of patient was uneventful. MD is found in 2%-4% of the population in large autopsy and surgical series. MD is mostly asymptomatic and incidentally discovered if not complicated; a debate exist about management of asymptomatic MD. Surgery represents the definitive treatment of complicated MD. MD is a true diverticulum rarely discovered in adults. Diagnosis of MD is difficult even with the help of radiological exams. Although surgical resection represents the correct treatment of symptomatic MD, nowadays there is no consensus on the optimal treatment of asymptomatic and incidentally discovered MD.

Sigmoid volvulus in a young woman nearly misdiagnosed as fecal impaction.

Volvulus of the sigmoid colon is a potentially life-threatening condition rarely seen in younger age groups and is male predominant. We report a previously healthy young woman with the triad of constipation, progressive abdominal distension, and severe abdominal pain, with plain-film x-ray studies mimicking stool impaction and computed tomography disclosing the typical findings of sigmoid volvulus. The case reminds Emergency Physicians to consider sigmoid volvulus if mechanical obstruction is suspected, even in a young patient. A 33-year-old woman had the triad of symptoms for 3 days. Physical examination did not show peritoneal signs. Digital rectal examination disclosed neither palpable mass nor stool in rectum. Computed tomography revealed "coffee bean" sign and "whirl" sign. Laparoscopy demonstrated redundant sigmoid colon and she was treated with detorsion with colopexy uneventfully. Sigmoid volvulus is rarely seen in developed countries. Clinical manifestations vary with disease progression, but it typically presents with a triad of constipation, progressive abdominal distension, and severe abdominal pain. Plain-film x-ray studies can demonstrate a coffee bean or "omega loop" (inverted-U sigmoid) sign in <60% cases, but it was reported as high as 86% in computed tomography. The whirl sign on computed tomography might also be observed. The cause is multifactorial and colonic length is the most important predisposing factor. Flexible colon fiberscopic decompression followed by elective definitive surgery is the treatment choice, but exploratory laparotomy is mandatory if any complicated entity occurs. The mortality rate is still >50% when bowel gangrene develops.

Bowel obstruction

Diagnosis The main diagnostic tools are blood tests, X-rays of the abdomen, CT scanning, and ultrasound. If a mass is identified, biopsy may determine the nature of the mass. Radiological signs of bowel obstruction include bowel distension and the presence of multiple (more than six) gas-fluid levels on supine and erect abdominal radiographs. Ultrasounds may be as useful as CT scanning to make the diagnosis. Contrast enema or small bowel series or CT scan can be used to define the level of obstruction, whether the obstruction is partial or complete, and to help define the cause of the obstruction. The appearance of water-soluble contrast in the cecum on an abdominal radiograph within 24 hours of it being given by mouth predicts resolution of an adhesive small bowel obstruction with sensitivity of 97% and specificity of 96%. Colonoscopy, small bowel investigation with ingested camera or push endoscopy, and laparoscopy are other diagnostic options.

[Intermittent incomplete ileus of the small intestine. Sonographic diagnosis and trends].

Intermittent incomplete intestinal obstruction was proven by sonography in 25 male and 48 female patients with an age range of 10 to 88 years. All of them suffered from intermittent colicky pain, nausea and meteorism followed by liquid stools. Only 52 patients had undergone a total of 69 abdominal operations. The pertinent symptoms could be traced back for 6 months to 10 years (4 +/- 3 years). In 47 patients, intake of bulky food during the last 12 to 48 hours triggered the onset of disorders. The preadmission diagnoses were: incomplete intestinal obstruction (only 21), gastroenteritis (15), biliary colic (13), peptic ulcer (10), renal colic (4), food intoxication (4), appendicitis (3), adnexitis (3). Sonographic findings were: inconstant lumen distension, visible bowel wall movements with contractions of 3 to 6 mm, food bolus, enhanced paradoxical peristalsis, proof of distended and collapsed gut segments, bowel wall edema and free peritoneal fluid. Based on these ultrasonic findings and trend observation, conservative treatment was successfully instituted. All patients were discharged symptom-free with no subsequent attacks for 12 months. 20 patients, subsequently suffering from complete intestinal obstruction after 1 to 3 years, were operated on, comprising 8 cases of intestinal resection, 7 cases of adhesiolysis and intestinal tube splinting, 3 cases of band dissection and 2 cases of palliative bypass procedures. The diagnostic accuracy of abdominal ultrasonography is clearly demonstrated by the fact, that 11 of these patients with intermittent incomplete intestinal obstruction and now suffering from complete obstruction had no previous abdominal surgery.

Ileosigmoid knot

An ileosigmoid knot is a form of volvulus in which ileum wraps around the base of the sigmoid and passes beneath itself forming a knot. The exact cause of this condition is not known. Patients usually present with clinical features of colonic obstruction. Vomiting, abdominal distension, abdominal pain, blood stained stools are frequent symptoms. It is difficult to diagnose this condition before surgery. Raveenthiran described a triad which may be useful in preoperative diagnosis. The triad includes 1). Clinical features suggestive of small bowel obstruction, 2). Radiological features suggestive of large bowel obstruction, 3). Inability to negotiate sigmoidoscope or a flatus tube. This is a surgical emergency that requires urgent resection of gangrenous bowel and untwisting of the volvulus. References Gastrointestinal tract disorders

Case Report: Caecal volvulus management from diagnosis to treatment in a young patient.

Caecal volvulus (CV) is a rare cause of intestinal obstruction, defined by an axial torsion of the caecum, ascending colon, and terminal ileum around the mesenteric vascular pedicles, leading to ischemia and bowel necrosis. A 20-year-old woman, with no significant medical history, was admitted for generalized abdominal pain evolving for three days, along with constipation and abdominal distension, but with no vomiting. Physical examination showed a generalized abdominal tenderness with no rigidity or rebound tenderness, associated with abdominal distension and tympanic upon percussion. Laboratory findings were within normal limits. An abdominal computed tomography scan revealed distension of a loop of the large bowel with its long axis extending from the right lower quadrant to the epigastrium or left upper quadrant. Colonic haustral pattern was absent. An abdominal computed tomography scan showed a rounded focal collection of air-distended bowel with haustral creases in the upper left quadrant. In addition, spiraled loops of the collapsed cecum (giving a whirl sign) were noted, along with low-attenuating fatty mesentery from the twisted bowel. The patient underwent an emergency laparotomy and caecectomy using GEA 80 charges. The patient had no complaints post-operation. CV is a rare cause of bowel obstruction, mainly caused by an exceedingly mobile caecum. Despite its rareness, CV represents the second most common cause of large bowel volvulus, behind sigmoid volvulus. For acute obstruction by CV, it is hard to differentiate it clinically from obstruction of the small bowel; therefore, radiological exams are needed. Surgery is the gold standard treatment for CV. We report a rare case of CV to highlight the rarity of this pathology, specify its diagnostic and therapeutic means, and its clinical and biological evolution.

Chronic Appendicitis-From Ambiguous Clinical Image to Inconclusive Imaging Studies.

A six-year-old boy visits a general practitioner due to diarrhea and abdominal pain with a moderate fever of up to 39 °C for 2 days. Treatment is initiated; however, the recurrence of abdominal pain is observed. Physical examination of the child at the emergency department reveals abdominal guarding and visible, palpable, painful intestinal loops in the left iliac and hypogastric regions-this is referred to as an 'acute abdomen'. An X-ray shows single levels of air and fluid indicative of bowel obstruction. Ultrasound reveals distended, fluid-filled intestinal loops with diminished motility. The intestinal wall is swollen. Laboratory tests indicate increased inflammatory indices. Contrast-enhanced computed tomography examination of the abdominal cavity and lesser pelvis shows intestinal dilation. The loops were filled with liquid content and numerous collections of gas. The patient is qualified for a laparotomy. An intraoperative diagnosis of perforated gangrenous appendicitis with autoamputation was made. In addition, numerous interloop and pelvic abscesses, excessive adhesions, signs of small intestine micro-perforation, and diffuse peritonitis are found. The patient's condition and laboratory parameters significantly improve during the following days of hospitalization. Despite the implementation of multidirectional, specialized diagnostics in the case of acute abdomen, in everyday practice we still encounter situations where the final diagnosis is made intraoperatively only.

Nausea

Diagnostic testing When a history and physical exam are not enough to determine the cause of nausea and vomiting, certain diagnostic tests may prove useful. A chemistry panel would be useful for electrolyte and metabolic abnormalities. Liver function tests and lipase would identify pancreaticobiliary diseases. Abdominal X-rays showing air-fluid levels indicate bowel obstruction, while an X-ray showing air-filled bowel loops are more indicative of ileus. More advanced imaging and procedures may be necessary, such as a CT scan, upper endoscopy, colonoscopy, barium enema, or MRI. Abnormal GI motility can be assessed using specific tests like gastric scintigraphy, wireless motility capsules, and small-intestinal manometry.

Bowel obstruction

Bowel obstruction, also known as intestinal obstruction, is a mechanical or functional obstruction of the intestines which prevents the normal movement of the products of digestion. Either the small bowel or large bowel may be affected. Signs and symptoms include abdominal pain, vomiting, bloating and not passing gas. Mechanical obstruction is the cause of about 5 to 15% of cases of severe abdominal pain of sudden onset requiring admission to hospital. Causes of bowel obstruction include adhesions, hernias, volvulus, endometriosis, inflammatory bowel disease, appendicitis, tumors, diverticulitis, ischemic bowel, tuberculosis and intussusception. Small bowel obstructions are most often due to adhesions and hernias while large bowel obstructions are most often due to tumors and volvulus. The diagnosis may be made on plain X-rays; however, CT scan is more accurate. Ultrasound or MRI may help in the diagnosis of children or pregnant women.

Volvulus

Signs and symptoms Regardless of cause, volvulus causes symptoms by two mechanisms: Bowel obstruction manifested as abdominal distension and bilious vomiting. Ischemia (loss of blood flow) to the affected portion of intestine. Depending on the location of the volvulus, symptoms may vary. For example, in patients with cecal volvulus, the predominant symptoms may be those of small bowel obstruction (nausea, vomiting and lack of stool or flatus), because the obstructing point is close to the ileocecal valve and small intestine. In patients with sigmoid volvulus, although abdominal pain may be present, symptoms of constipation may be more prominent.

[Investigation of diagnostic method and treatment on acute appendicitis with acute intestinal obstruction as presenting manifestation].

Prevention of the misdiagnosis of acute appendicitis when it first manifested as acute intestinal obstruction, and to search proper way of diagnosis and treatment for such event to provide the reference. Clinical data of 33 acute appendicitis cases presented with acute intestinal obstruction in Beijing Tong Ren Hospital during January 2000 and December 2015 were analyzed retrospectively. All 33 patients were admitted to the Emergency Department with symptoms of various degrees abdominal pain and abdominal distension. There was no passage of gas and feces. The mean time of onset was (62.2±25.0) hours. The imaging examination showedthat all patients had complete bowel obstruction. Twenty one patients(63.6%) had peritonitis, three of whom developed with septic shock. Abdominal CT was performed in 17 patients preoperatively, which showed retention of gas and fluid in the small intestine in all the patients and 13 were suggestive of acute appendicitis. All of these patients received surgical treatment, 12 patients underwent laparoscopic exploration, and the remaining 21 patients received exploratory laparotomy during which acute appendicitis was confirmed to be the cause of intestinal obstruction, of whom 14(42.4%) was identified as mechanical intestinal obstruction. Nine patients underwent appendectomy and lysis of adhesion, five appendectomy and partial excision of the greateromentum. Nineteenpatients(57.6%) were identified as paralytic ileus and underwent appendectomy only. Twelve patients required respiratory and circulatory support and were admitted to ICU postoperatively. The mean duration time in ICU was(8.8±5.2) days. Postoperative pathology showedgangrene accompanied with perforation in the appendix. All patients were discharged without any complication. The length of hospital stay was (15.4±4.6) days. All patients were followed up for 3 ~ 12 months. One patient with chronic obstructive pulmonary disease developed repeated pulmonary infection and died of respiratory failure at 185 days postoperatively. The remaining patients were followed up and there were no patients developed intra-abdominalsepsis, intestinal obstruction, surgery-related complications, or death. Patients with acute appendicitis presenting with acute intestinal obstruction are mostly in severe condition. Clinical diagnosis for this patients is difficult and surgery should be performed as soon as possible.

Distal intestinal obstruction syndrome

Distal intestinal obstruction syndrome (DIOS) involves obstruction of the distal part of the small intestines by thickened intestinal content and occurs in about 20% of mainly adult individuals with cystic fibrosis. DIOS was previously known as meconium ileus equivalent, a name which highlights its similarity to the intestinal obstruction seen in newborn infants with cystic fibrosis. DIOS tends to occur in older individuals with pancreatic insufficiency. Individuals with DIOS may be predisposed to bowel obstruction, though it is a separate entity than true constipation. Signs and symptoms Signs and symptoms of DIOS include a sudden onset of crampy abdominal pain, vomiting, and a palpable mass (often in the right lower quadrant) in the abdomen. The characteristic abdominal pain is typically located in the center or right lower quadrant of the abdomen. X-rays of the abdomen may reveal stool in the colon and air-fluid levels in the small intestines.

Necrotizing enterocolitis

Diagnosis is usually suspected clinically, but often requires the aid of diagnostic imaging, most commonly radiography, which can show the intestines and may show areas with death tissue or a bowel perforation. Specific radiographic signs of NEC are associated with specific Bell's stages of the disease: Bell's stage 1 (suspected disease): Mild systemic disease (apnea, lethargy, slowed heart rate, temperature instability) Mild intestinal signs (abdominal distention, increased gastric residuals, bloody stools) Nonspecific or normal radiological signs Bell's stage 2 (definite disease): Mild to moderate systemic signs Additional intestinal signs (absent bowel sounds, abdominal tenderness) Specific radiologic signs (pneumatosis intestinalis or portal venous gas) Laboratory changes (metabolic acidosis, too few platelets in the bloodstream) Bell's stage 3 (advanced disease): Severe systemic illness (low blood pressure)

Volvulus -- Evaluation

Diagnosis of colonic volvulus is clinical, however, radiological investigations are often required for diagnostic confirmation due to an overlap of clinical features with other diseases. The first investigation to be performed is a plain radiograph of the abdomen. Specific signs including "bent inner tube" or a "coffee bean" sign are characteristic for sigmoid volvulus. These refer to the appearance of the air-filled closed loop of the colon which forms the volvulus revealing a thick inner and a thin outer wall. Similarly, plain radiographs of patients with cecal volvulus reveal distended small bowel and large bowel. Contrast enema should be performed only after perforation peritonitis is ruled out. Demonstration of a "bird's beak" at the point where the colon rotates to form the volvulus is characteristic of sigmoid volvulus. Computed tomography (CT) of the abdomen and pelvis is generally not indicated in patients with colonic volvulus, however, when performed an upward displacement of the appendix with large and small bowel obstruction is suggestive for cecal volvulus. [7] Similar to colonic volvulus, in children with midgut volvulus, radiological features include paucity of gas throughout the intestine with few scattered air-fluid levels on plain radiograph, and an abnormally placed duodenojejunal junction (DJ) with the small bowel looping entirely on the right side of the abdomen on upper GI series. [5] Laboratory studies including complete blood count (CBC) and serum biochemistry may show a left shift with leucocytosis and electrolyte abnormalities respectively, however, these are non-specific.

Bowel obstruction

Signs and symptoms Depending on the level of obstruction, bowel obstruction can present with abdominal pain, swollen abdomen, abdominal distension, and constipation. Bowel obstruction may be complicated by dehydration and electrolyte abnormalities due to vomiting; respiratory compromise from pressure on the diaphragm by a distended abdomen, or aspiration of vomitus; bowel ischemia or perforation from prolonged distension or pressure from a foreign body. In small bowel obstruction, the pain tends to be colicky (cramping and intermittent) in nature, with spasms lasting a few minutes. The pain tends to be central and mid-abdominal. Vomiting may occur before constipation. In large bowel obstruction, the pain is felt lower in the abdomen and the spasms last longer. Constipation occurs earlier and vomiting may be less prominent. Proximal obstruction of the large bowel may present as small bowel obstruction. Causes Small bowel obstruction

Bowel obstruction

A small flexible tube (nasogastric tube) may be inserted through the nose into the stomach to help decompress the dilated bowel. This tube is uncomfortable but relieves the abdominal cramps, distention, and vomiting. Intravenous therapy is utilized and the urine output is monitored with a catheter in the bladder. Most people with SBO are initially managed conservatively because in many cases, the bowel will open up. Some adhesions loosen up and the obstruction resolves. The patient is examined several times a day, and X-ray images are made to ensure he or she is not getting clinically worse. Conservative treatment involves insertion of a nasogastric tube, correction of dehydration and electrolyte abnormalities. Opioid pain relievers may be used for patients with severe pain. Antiemetics may be administered if the patient is vomiting. Adhesive obstructions often settle without surgery. If the obstruction is complete surgery is usually required.

[Rational diagnostics of acute abdomen].

In view of the threat that comes with an acute abdomen, it is of major importance that diagnostics are executed quickly and efficiently. In the course of this two tendencies can be differentiated: 1) general use of complex examination (e.g. CT, MRT) of all potential patients and 2) step-by-step-diagnostics with advanced diagnostics as and when required. A total of 444 patients with an acute abdomen as admission diagnosis were investigated. All data were evaluated prospectively and analyzed retrospectively. All patients had the same basic diagnostics consisting of aclinical history, clinical examination, laboratory examination, abdominal sonography and x-ray overview images. These examinations were supplemented when required by advanced measures, such as CT, colon enema with contrast fluid, endoscopic examination and diagnostic laparotomy. Three different disease groups of unequal diagnostic need could be identified. The first group, presented in the form of an appendicitis showed that in 80% of all patients a basic diagnosis was sufficient. Advanced examination such as CT affected 14%. The negative appendectomy rate amounted to 8%. Other diseases belonging to the first group were ileus, acute biliary diseases, perforation etc. In the second group presented in the form of a diverticulitis, an advanced radiological examination was required in 84% of all cases. Similar results are also expected in cases of pancreatitis. In the third group presented in the form of coprostasis, inflammatory etiology was found in 39% of all secondary diseases. However the symptoms became clinically apparent after treatment of the coprostasis. In this group a basic diagnosis was satisfactory in 84% of cases, however, a diagnostic laparotomy was inevitable for 3% of these patients. Generally step-by-step diagnostic approach has proven itself to be efficient. For 80% of all patients it makes advanced diagnostic measures unnecessary. The exceptions are diseases in which it is necessary to know not only the diagnosis but also the disease stage. In these cases (e.g. pancreatitis, diverticulitis etc.) advanced diagnostics should be pursued from the onset. The necessity of a diagnostic laparotomy has lost importance for 1% of all patients.

Surgery_Schwartz

Older patients tend to require a longer time for full recovery.Management of the Child With Perforated Appendicitis. The signs and symptoms of perforated appendicitis can closely mimic those of gastroenteritis and include abdominal pain, vom-iting, and diarrhea. Alternatively, the child may present with symptoms of intestinal obstruction. An abdominal mass may be present in the lower abdomen. When the symptoms have been present for more than 4 or 5 days, and an abscess is suspected, it is reasonable to obtain a computerized tomogram of the abdo-men and pelvis with IV, oral, and rectal contrast in order to visu-alize the appendix and the presence of an associated abscess, phlegmon, or fecalith (Fig. 39-21).An individualized approach is necessary for the child who presents with perforated appendicitis. When there is evidence of generalized peritonitis, intestinal obstruction or evidence of systemic toxicity, the child should undergo appendectomy. This should be delayed only for as long

[Diverticulitis appendicis vermiformis--a case review and literature overview].

Diverticulosis and diverticulitis of appendix vermiformis is a rare diagnosis with incidency of 0.004-2%. Because of intermittent pain and atypical problems patients with diverticulitis are surgically intervened later as patients with simplex appendicitis. Complications in regard to perforation of appendix are more frequent in 27% in diverticulitis and mortality of consequent peritonitis is 30 times higher than in simplex appendicitis. Authors present 0.1% incidency of diverticulitis of appendix in the group of 1496 patients with appendicitis. The case involved a man and a woman (age 59 and 61). In clinical picture predominated pain with the duration of two and three days with maximum in right lower abdomen. Patients showed no febrility, one of them had anorexia and constipation, one of them suffered from diarrhea. Mantrels score reached 5 and 7 points. In laboratory parameters elevated inflammatory markers (Leu: 1.5 x 10(9)/l, 11.44 x 10(9)l; CRP: 182 mg/l, 96.3 mg/l) were detected. Ultrasonographic examination determined the diagnosis of subacute appendicitis in one case, a perforation of sigmoid diverticle in the second case. Appendectomy was performed in both patients, there was a finding of gangrenous and phlegmonous appendicitis. In both patients, a correct diagnosis of diverticulitis was determined only through histopathological examination. Clinical and laboratory examinations did not showed a difference between progress of disease of diverticulitis and simplex appendicitis. In comparison to a control group, only a higher CRP was determined and also a 35 years higher age average. In neither case did the USG examination determine the exact diagnose. Urgent surgical operation prevented frequent complications presented in the literature.

Large Bowel Obstruction -- Evaluation

The patient should have the standard blood work (full blood count and renal function tests), to aid resuscitation and assess the kidney function for a potential computed tomography scan with contrast. [7] [8] [9] A plain abdominal x-ray will show the dilated colon, and a cutoff in the area of obstruction, as well as a paucity of gas in the rectum, or a classical coffee bean sign in the case of a volvulus. If a colonic malignancy is suspected, a computed tomogram (CT) of thorax, abdomen, and pelvis will stage the disease and allow for further management.

Abdominal x-ray

An abdominal x-ray is an x-ray of the abdomen. It is sometimes abbreviated to AXR, or KUB (for kidneys, ureters, and urinary bladder). Indications In children, abdominal x-ray is indicated in the acute setting: Suspected bowel obstruction or gastrointestinal perforation; Abdominal x-ray will demonstrate most cases of bowel obstruction, by showing dilated bowel loops. Foreign body in the alimentary tract; can be identified if it is radiodense. Suspected abdominal mass In suspected intussusception, an abdominal x-ray does not exclude intussusception but is useful in the differential diagnosis to exclude perforation or obstruction. Yet, CT scan is the best alternative for diagnosing intra-abdominal injury. Computed tomography provides an overall better surgical strategy planning, and possibly less unnecessary laparotomies. Abdominal x-ray is therefore not recommended for adults with acute abdominal pain presenting in the emergency department. Projections

Acute abdomen. When to operate immediately and when to observe.

When to operate immediately, when to observe, and when not to operate at all represent major challenges in the management of a child with an acute abdomen. This article is an overview of the subject from symptom to diagnosis, evaluation, and preparation for the surgical intervention. Tables provide examples of conditions requiring prompt surgical intervention and relative surgical urgency; pathologies suitable for (initial) nonsurgical management; and clinical pictures where surgical intervention is not indicated. Factors that influence the timing of operation are provided, as is the differential diagnosis between intestinal strangulation and obstruction. Brief notes highlight four important causes of acute abdomen in children acute appendicitis, malrotation with volvulus, Meckel's diverticulum, and intussusception. These as well as other intraabdominal pathologies are illustrated by means of surgical photographs. The acute abdomen is a clinical diagnosis. Other diagnostic modalities have merely supporting roles. The decision to operate is based primarily on the results of a good history and thorough physical examination(s).

The demise of the instant/unprepared contrast enema in large bowel obstruction.

Imaging the colon in suspected acute large bowel obstruction (LBO) is traditionally carried out with a supine abdominal X-ray (AXR) and erect chest X-ray. If there is no clinical or radiological evidence to suggest a perforation, then an unprepared barium or water-soluble contrast enema (CE) can be performed to confirm the presence of and demonstrate the site of obstruction. The advent of modern, fast multidetector CT (MDCT) scanners has changed management strategies for acute abdominal conditions including suspected LBO in all groups of patients especially the elderly, infirm and those on ITU/HDU. A retrospective case note analysis was carried over a 7-year period in a single centre. The study criteria involved investigation of suspected LBO with CE, CT and MDCT. It showed a reduction in the number of contrast enemas performed. MDCT was shown to be more accurate in the diagnosis of LBO, is usually available on a 24-h basis, and in many institutions has replaced the urgent CE in this group of patients. This also has the advantage of excluding incidental findings and in staging malignant disease.

Intussusception (medical disorder)

Intussusception is a medical condition in which a part of the intestine folds into the section immediately ahead of it. It typically involves the small bowel and less commonly the large bowel. Symptoms include abdominal pain which may come and go, vomiting, abdominal bloating, and bloody stool. It often results in a small bowel obstruction. Other complications may include peritonitis or bowel perforation. The cause in children is typically unknown; in adults a lead point is sometimes present. Risk factors in children include certain infections, diseases like cystic fibrosis, and intestinal polyps. Risk factors in adults include endometriosis, bowel adhesions, and intestinal tumors. Diagnosis is often supported by medical imaging. In children, ultrasound is preferred while in adults a CT scan is preferred.

[New findings in the differential diagnosis of acute ileus (author's transl)].

Knowledge of the patho-physiological behaviour present in the colon is the deciding factor for a reliable differential diagnosis of mechanical or paralytic ileus. A quick and sure diagnosis can be got with irrigoscopy (barium enema). In paralytic ileus, a radical change in the function of the right colon is present; instead of resorption, exudation and paralysis have taken place. Barium enema shows this behaviour; the left colon stays contracted, the contrast medium passes easily into the right colon, where it mixes with the fluid levels. This picture is proof of paralytic ileus. A completely different picture is to be found in mechanical ileus of the small intestine; the small intestine is gas-inflated, with fluid levels, and passes nothing on to the colon which, therefore, is contracted in its whole length. This picture also is diagnostic. Barium enema is already known in the diagnosis of mechanical ileus of the large intestine. It can also be used in the diagnosis of paralytic enterocolitis (without diarrhoea) in childhood and old age. In the case of post-operative early ileus it gives a quick and sure differential diagnosis.

Extensive small bowel metastasis and peritoneal dissemination 1 year following curative gastrectomy for T1N1 gastric cancer: A case report.

Metastasis of T1N1 gastric cancer (GC) at early stage after curative gastrectomy is unusual. Reports on the diagnosis, treatment, and prognosis of peritoneal metastasis following curative gastrectomy for T1N1 GC are lacking. A 54-year-old woman was admitted to our hospital with complaints of mild abdominal distension and failure to pass gas and stool for 2 days. She has a history of distal gastrectomy for T1N1 GC. About 1 year after surgery, she presented with persistent abdominal distension and underwent conservative managements. Imaging tests failed to identify the apparent cause of intestinal obstruction. When conservative managements failed to relieve the symptoms, she underwent emergency laparotomy, which revealed extensive small bowel metastasis and peritoneal dissemination. Peritoneal irrigation and drainage were performed with the consent of the patient's families. The patient abandoned further therapy and died 1 week later during the follow-up period. Although the metastasis of T1N1 GC is rare, patients with high risk of metastasis after curative surgery should also be closely followed and be considered as candidates for more aggressive screening strategies. In addition, the use of more effective chemotherapeutic drugs as adjuvant chemotherapy after curative surgery in T1N1 patients may also need to be explored.

Early diagnosis of bowel motility disorders, with US in urgency, compared to conventional X-ray investigation: personal collection and literature.

Ultrasound investigation is more and more useful instrumental investigation, for early detection of rising signs of bowel occlusion, if compared to conventional abdominal x-ray. A personal collection of 25 intestinal occlusions is reported, comparing the conventional radiographic and ultrasonographic essays. The static x-ray of abdomen didn't reveal adynamic condition in 11/15 patients, confirmed by US supporting clinical examination; 4/25 has been even treated conservatively, completely restored, though radiological diagnosis of occlusion, relying on clinical and sonographic reports. In 9/25 subjects x-ray has not been performed, relying on US only to achieve instrumental diagnosis. The most important advantage of echography, such as dynamic evaluation, allows the study of potential mechanical peristaltic disorders, revealing the stratification of liquid and gas enteric contents, one of the most peculiar sign of intestinal occlusion. Supporting clinical suspect, in the reported collection, it recruited on one hand early surgical solution for the most of them and conservative approach for five patients on the other.

Ileo-sigmoid knotting- an unusual cause of intestinal obstruction: A case report.

Ileosigmoid knotting is an unusual cause of intestinal obstruction in which the ileum wraps around the base of the sigmoid colon and its mesentery, which leads to a closed loop intestinal obstruction. A 59-year-old male patient was referred to our center with acute abdominal pain, obstipation and a few episodes of vomiting. On physical examination, he had hypotension and tachycardia as well as distension, diffused tenderness, guarding and rebound tenderness of the abdomen. Bowel sounds were absent. Abdominal Plain X-ray showed dilatation of the large bowel associated with the distended small bowel. After resuscitation with aggressive intravenous fluid therapy, the patient underwent an emergency laparotomy. Exploration revealed gangrene of the intestinal loops, including the jejunum and ileum, which was secondary to a 360° clockwise twisting of the ileal loops around the sigmoid colon. Gangrene of the sigmoid colon along with torsion of the superior mesenteric arteries was also obvious. Resection of the gangrenous loops of the small bowel as well as a sigmoidopexy was carried out and a primary anastomosis of the small intestine and colon was performed. He did well post-operatively. It is crucial to distinguish Ileosigmoid knotting from sigmoid volvulus because it can rapidly, even within hours, progress to bowel gangrene and peritonitis; moreover, in this situation the endoscopic reduction is contraindicated. Ileosegmoid knotting is an unusual cause of bowel obstruction which has relatively high mortality rates and should be considered in patients with acute abdominal pain and presentations of bowel obstruction.

Use of Postmortem Computed Tomography to Detect Bowel Obstruction and its Relationship to the Cause of Death.

Bowel distension frequently indicates bowel obstruction, which is a common diagnosis in clinical radiology. Typically, symptoms and complaints lead to radiological examinations and the detection of the etiology. Untreated intestinal obstructions can lead to a fatal outcome through cardiac failure due to septic shock. Certain of these cases undergo medicolegal investigations depending on the case history, the condition of the decedent, the location of the finding, or recent visits to medical professionals. Computed tomography (CT) is a recommended method in clinical radiology for the detection of bowel obstruction, which is indicated by bowel distension and further radiological signs (eg, the whirl sign, which indicates a volvulus). Postmortem CT (PMCT) has increased worldwide, but PMCT differs from clinical CT; thus, the question of whether PMCT is also reliable for the detection of bowel obstruction in decedents or is negatively affected by postmortem modifications should be discussed. This study consists of 10 cases displaying radiological signs of bowel obstruction. Apart from bowel distension, the most common radiological signs (whirl sign, coffee bean sign, bird beak sign, and u-shape sign) are described and depicted. All decedents underwent autopsy and had a postmortem interval of less than 72 hours. Based on these cases, we assess the reliability of PMCT for detecting bowel obstruction and determining its relationship to the cause of death.

Chronic diarrhea of infancy

Hirschsprung's disease (HSCR), a gut motility disorder characterized by a lack of nerve cells in the large intestine which are needed to move the stool through the digestive tract. In infants, HSCR typically presents when a newborn is unable to pass the first feces, or meconium within 48 hours of birth. Other symptoms include blockage of the intestine, fever, rapid release of stool and flatulence upon rectal examination, and may present with diarrhea in infants. Intestinal pseudo-obstruction (IPO), a gut motility disorder characterized by the inability to contract intestinal walls with symptoms similar to intestinal obstruction but lack a distinguishable cause of obstruction. Signs and symptoms include abdominal pain, dilated or enlarged bowel, constipation and may include diarrhea. Although rare in infants, IPO is a type of congenital disorder that may present with diarrhea in infants.

Simple data from history and physical examination help to exclude bowel obstruction and to avoid radiographic studies in patients with acute abdominal pain.

To assess the value of plain abdominal radiographs and of data from the medical history and physical examination in the diagnosis of acute abdominal pain in general and of bowel obstruction in particular. Prospective study. 4 university and 2 community hospitals, Germany. 1254 patients with acute abdominal pain lasting less than 7 days, and with no history of abdominal injury including surgery. Standardised and structured medical history and physical examination, study of results of plain abdominal radiographs. Positive predictive value and sensitivity of clinical variables and abdominal film with respect to the diagnosis at discharge. 48 patients (3.8%) had bowel obstruction. 704 patients (56.1%) had plain abdominal films taken at the time of initial presentation. 111 studies (15.8%) showed important findings leading to diagnosis or immediate treatment, 455 (64.7%) showed unimportant or no findings. In 138 (19.6%) results of films were not reported. 16 of 45 single variables were of help in diagnosing bowel obstruction. The six with the highest sensitivity were distended abdomen, increased bowel sounds, history of constipation, previous abdominal surgery, age over 50, and vomiting. If only patients presenting with any two of these symptoms had had radiographs taken, 300 (42.6%) could have been avoided without loss in diagnostic accuracy. A considerable number of plain abdominal films taken for patients with acute abdominal pain could be avoided by focusing on clinical variables relevant to the diagnosis of bowel obstruction.