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• Megacolon is a rare clinical condition consisting of an abnormally dilated colon in the absence of mechanical obstruction. • Megacolon can complicate pregnancy in terms of maternal morbidity and mortality and obstetrical outcomes. Pregnancy, on the other hand, can exacerbate chronic constipation through hormonal and mechanical mechanisms. • A case of megacolon is reportedpresenting accidentally during the routine mid-trimester fetal ultrasound as a suspicious pelvic mass of unknown aetiology (mean diameter > 10 cm). • Chronic constipation in women of reproductive age should receive greater clinical attention during pre- and periconception care. • A multi-disciplinary approach, timely diagnosis and delivery planning are fundamental to ensure favourable outcomes for both the mother and fetus when dealing with megacolon during pregnancy. Megacolon is a rare clinical condition consisting of an abnormally dilated colon in the absence of mechanical obstruction. Megacolon can complicate pregnancy in terms of maternal morbidity and mortality (volvulus, ileus, systemic toxicity, bowel perforation, sepsis) and obstetrical outcomes (preterm birth, premature rupture of membranes, dystocia). Pregnancy, on the other hand, can exacerbate chronic constipation through hormonal and mechanical mechanisms. A case of megacolon, first detected during pregnancy in an otherwise healthy nulliparous woman, is reported. The diagnosis was suspected on observation of a pelvic mass of unknown aetiology (mean diameter > 10 cm) constricting and dislocating the gravid uterus contralaterally during a routine mid-trimester fetal ultrasound. The diagnostic work-up and management are discussed. Chronic constipation in women of reproductive age should receive greater clinical attention during pre- and periconception care. A multi-disciplinary approach, timely diagnosis and delivery planning are fundamental to ensure favourable outcomes for both the mother and fetus when dealing with megacolon during pregnancy. [ABSTRACT FROM AUTHOR]

This study aimed to examine the characteristics of nasal and imaging findings of sinonasal lesions in granulomatosis with polyangiitis (GPA) patients and how these lesions change over time in both the active and remission phases of the disease. We retrospectively reviewed GPA patients with sinonasal lesions who were followed up at our department between January 2005 and December 2020. The following data were collected: age, sex, symptoms at initial presentation, anti-neutrophil cytoplasmic antibody (ANCA) type, and histopathological, nasal (initial and follow-up), and imaging (initial and follow-up) findings. This study included 17 patients with GPA aged 30 to 79 years. Computed tomography (CT) of the sinuses showed mucosal thickening in 16 patients, bone thickening in 12, bone destruction in 4, and an orbital invasion mass in 3 at the time of diagnosis. After initiating treatment, mucosal thickening of the sinuses improved in 3 of 16 patients and remained unchanged in 13. Bone thickening at the time of diagnosis remained unchanged in 10 of 12 patients and worsened in 2; 1 patient displayed newly developed bone thickening. Destructive nasal findings on CT were positive for proteinase 3-ANCA. Our study revealed that mucosal thickening, bone thickening, bone destruction, and orbital invasion mass were major CT findings in patients with GPA. Intranasal findings such as granulations, crusting, and necrosis were seen in the active phase; moreover, saddle nose, loss of turbinate, and nasal septal perforation were subsequently seen in the course of the disease. Sinonasal findings of GPA vary depending on the disease stage and period. [ABSTRACT FROM AUTHOR]

To assess the clinical complications reported after the ingestion of magnetic foreign bodies (FBs) in pediatric age, along with their incidence among all FB ingestions and clinical presentation. We've consecutively recruited all children aged 0–14 years who were admitted for single or multiple magnet ingestion from May 2015 to December 2022. Patient demographics, admission sources and discharge status were accurately recorded, along with their clinical management and outcomes. Sixty-one children were enrolled, of whom 49/61 (80.3%) had ingested a single magnet and 12/61 (19.7%) multiple magnets. Only 1/49 children with single magnet required endoscopic removal due to esophageal retention. Among children having ingested multiple magnets, 5/12 (41.7%) undergo endoscopic removal since magnets were amenable to endoscopic retrieval whereas in 7/12 (58.3%) magnets could not be promptly removed. Among these, 4/12 (33.3%) later developed intestinal ischemia/necrosis or perforation and required FB surgical intervention whereas 3/12 (25%) uneventfully evacuated magnets. Our data confirm that multiple magnet ingestion, unlike single magnet ingestion, pose a serious health hazard. Parents and caregivers should remove them from the reach of children. Medical providers should maintain a high index of suspicion of their ingestion since prompt evaluation and likely removal may be lifesaving and intestine saving. [ABSTRACT FROM AUTHOR]

Magnetic foreign body ingestion poses a threat especially if more than one is ingested. If consumed alone, small magnetic foreign bodies are likely to pass without significant event; however, when multiple magnets are ingested, they can be attracted to each other through the intestinal wall, which may lead to serious consequences and complications, including bowel perforation, obstruction, peritonitis, and death. We report a case of a 2-years male child patient presented with multiple small round magnetic beads ingestion from a magnetic pendant that appeared like a necklace pearl after conglomeration on abdominal radiograph. On exploration, we found multiple perforations involving ileum, cecum, and transverse colon, with multiple conglomerated beads extruding from the perforation sites. [ABSTRACT FROM AUTHOR]

Gastrointestinal perforation in extremely low birth weight infants, characterized by its rapid onset, multiple complications, and critical condition, poses a significant risk of infant mortality. The aim of this study was to investigate the clinical characteristics of pneumoperitoneum in extremely low birth weight infants (ELBWI) and explore the risk factors associated with gastrointestinal perforation in very low birth weight preterm infants. Additionally, we shared our surgical experiences in managing gastrointestinal perforation among extremely low birth weight infants. The Department of Neonatology at Chengdu Women and Children's Central Hospital conducted a retrospective study on gastrointestinal perforation in extremely low birth weight infants (birth weight <1000 g) who were admitted between 2014 and 2021. After baseline analysis and comparing it with the control group, we identified the risk factors associated with gastrointestinal perforation in ELBWI by multiple logistic regression analysis. The Kaplan-Meier analysis was performed to assess the adverse effect of gastrointestinal perforation for survival in ELBW infants. Cox multivariate regression analysis was used to evaluate hazard level of different variables for ELBW infants survival. Hemodynamically significant patent ductus arteriosus (hsPDA)(p = 0.043, OR = 2.779) and sepsis (p = 0.014, OR = 2.265) were significant risk factors for gastrointestinal perforation in extremely low birth weight infants. The Cox proportional hazard model revealed that intraventricular hemorrhage (HR = 2.854, p＜0.001) Sepsis (HR = 1.645, p = 0.015) and gastrointestinal perforation (HR = 1.876, p = 0.008) had detrimental effects on the survival of extremely low birth weight infants; conversely, ibuprofen (HR = 0.304, p＜0.001) and blood transfusion (HR = 0.372, p＜0.001) are beneficial factors for their survival. The preoperative indicators of infection in infants with spontaneous intestinal perforation (SIP) were significantly better than those in the necrotizing enterocolitis (NEC) group (p < 0.05). Gastrointestinal perforation poses a significant threat the survival of extremely low birth weight (ELBW) infants, with hsPDA and sepsis serving as predisposing factors for gastrointestinal perforation. The gastrointestinal perforation caused by various diseases exhibits distinct clinical characteristics, necessitating tailored surgical approaches based on operative conditions. [ABSTRACT FROM AUTHOR]

Malignant bowel obstruction (MBO) is a common complication of intra-abdominal cancer, frequently seen in advanced gastrointestinal and gynecologic cancer. Management of MBO can be challenging, particularly if the patient is not a surgical candidate. No consensus exists on how best to manage these patients medically. Retrospective studies suggest that the combination of dexamethasone, octreotide and metoclopramide may lead to relief of obstruction and improvement in symptoms associated with the obstruction. This study seeks to prospectively evaluate the combination of drug "triple therapy" dexamethasone 4 mg BID, metoclopramide 10 mg Q6 and octreotide 300 mcg TID to assess tolerability, safety, and effect on symptoms and deobstruction. Adults admitted at Roswell Park Comprehensive Cancer Center with malignant bowel obstruction were eligible. Eligible patients who constented to the study were started on the triple therapy with close monitoring of symptoms and for adverse effects. A total of 15 patients enrolled in the study. Two patients experienced bradycardia as adverse effect and there was no incidence of bowel perforation. All patients who completed the study had complete resolution of their nausea, and improvement in other symptoms including pain, constipation, tolerance of oral intake and resumption of bowel movements. Only two of the 15 patients were alive to complete the six-month post study follow up. "Triple therapy" with dexamethasone, metoclopramide, and octreotide for management of nonsurgical MBO in this small sample size appears safe and well tolerated however a diagnosis of inoperable MBO remains associated with poor prognosis and death within months. [ABSTRACT FROM AUTHOR]

Intestinal perforation is described in coeliac disease in the setting of refractoriness or Enteropathy-Associated T-cell Lymphoma (EATL). We report the case of a man with untreated coeliac disease who presented intestinal perforation and was diagnosed with EATL over one year later. [ABSTRACT FROM AUTHOR]

The health and safety hazards related to button batteries (BB) have been extensively studied, highlighting that the presence of a button battery in the esophagus is a life-threatening emergency. However, complications related to bowel BB are poorly evaluated and not well known. The objective of this review of the literature was to describe severe cases of BB that have passed the pylorus. This case, from the PilBouTox cohort, is the first report of small-bowel occlusion following ingestion of an LR44 BB (diameter: 11.4 mm) by a 7-month-old infant with a history of intestinal resections. In this case, the BB was ingested without a witness. The initial presentation mimicked acute gastroenteritis evolving into hypovolemic shock. An X-ray revealed a foreign body stuck in the small bowel causing an intestinal occlusion and local necrosis without perforation. The patient's history of intestinal stenosis and intestinal surgery were the contributing factor of impaction. The review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. The research was conducted on September 12, 2022 through five database and the U.S. Poison Control Center website. An additional 12 severe cases of intestinal or colonic injury after ingestion of a single BB were identified. Of these, 11 were related to small BBs (< 15 mm) that impacted Meckel's diverticulum and one was related to postoperative stenosis. In view of the findings, the indications for digestive endoscopy for extraction of a BB in the stomach should include a history of intestinal stenosis or intestinal surgery so as to avoid delayed intestinal perforation or occlusion and prolonged hospitalization. [ABSTRACT FROM AUTHOR]

This study was conducted to evaluate the clinical efficacy and safety of computed tomography (CT)-guided 125I implantation in the treatment of recurrent or metastatic pelvic malignant tumor. This retrospective study analyzed the data of 30 patients with recurrent and metastatic pelvic malignant tumor who were treated with CT-guided 125I implantation between January 2016 and December 2020. Disease control rate, objective remission rate, overall survival (OS), pain relief rate, quality of life score, and complications were evaluated after the followup. Median followup was 20.1 (7–30) months. Disease control rate was 86.67% at 6 months. Objective response rates at 1, 3, and 6 months were 36.67%, 60%, and 56.67%, respectively. OS rates at 12 and 24 months were 76.67% (23/30) and 33.33% (10/30), respectively. Progression-free survival rates at 12 and 24 months were 63.33% (19/30) and 33.33% (10/30), respectively. Postoperative pain relief rate was 86.67% (26/30). There were no major bleeding, pelvic abscess, intestinal fistula, intestinal perforation, and other serious complications. CT-guided 125I seed implantation in the treatment of patients with pelvic malignant tumor is a simple operation and less traumatic and can improve patients' quality of life and reduce tumor load. [ABSTRACT FROM AUTHOR]

• Early abdominal complications are frequent after lung transplantation. • A high percentage of abdominal complications require invasive treatment. • Hemodynamic instability is a risk factor for abdominal complications. Patients undergoing lung transplantation (LT) are at high risk of developing serious abdominal complications, which can lead to higher rates of morbidity and mortality. The aim of this study was to investigate the incidence and spectrum of these complications when they develop during the first 30 days after LT, as well as their possible association with possible risk factors. A retrospective study of 552 patients undergoing LT between 01/02/2006 and 06/03/2021 was carried out. A descriptive and analytical evaluation of the patients who experienced complications and those who did not was performed comparatively. Data related to patient characteristics and the lung transplantation procedure were collected. Overall, 8.2% of patients developed severe abdominal complications during the first 30 days; paralytic ileus was the most frequent (31.1%), closely followed by visceral perforation (26.7%). The percentage of patients who required an invasive procedure to manage post-transplant complications was 57.8%. Surgical intervention was required in 39.8%. The variables that showed a significant relationship with the development of severe short-term abdominal complications in the univariate analysis were the time of surgery, the use of ECMO/ ECC and red blood cell transfusion during or after surgery. In the multivariate study, however, only duration of surgery remained significant (p=0.03). The incidence of severe short-term abdominal complications after LT period was 8%. The commonest complications were paralytic ileus and intestinal perforation. Most patients did not require surgery. The only risk factor found associated with these complications was the duration of the surgical intervention. [ABSTRACT FROM AUTHOR]

1. Implement EMR enhancements prompting inpatient providers to consider scheduling bowel care when ordering scheduled opioids for admitted cancer patients on chronic opioid therapy. 2. Track changes in use of opioid-constipation reversal medications and constipation-induced complications. In cancer patients on chronic opioid therapy, those with constipation have substantially higher total healthcare costs. This QI brings a prophylactic focus to opioid-induced constipation in opioid-prescribed patients in the inpatient setting via electronic medical record (EMR) enhancements. Abstract: Introduction/Context: Opioid-induced constipation can significantly impair patient quality of life and satisfaction, with patients experiencing substantial burdens in mental health, activities of daily living, and incurring high health care costs with a subsequent economic burden (Argoff 2020). For patients treated with strong opioids over a six-month period, total costs per patient month increased with increasing degree of constipation (Hjalte 2010). Specifically in cancer patients on chronic opioid therapy, those with constipation had substantially higher total healthcare costs, including greater utilization of inpatient services, emergency evaluation, clinic office visits, and nursing home care (Candrilli 2009). Focusing on opioid-induced constipation has shown to decrease odds of hospitalization and re-encounters in the emergency department (Peacock 2022). 1.Implement EMR enhancements prompting inpatient providers to consider scheduling bowel care when ordering scheduled opioids for admitted cancer patients on chronic opioid therapy. 2. Track changes in use of opioid-constipation reversal medications and constipation-induced complications. Proposed EMR enhancements include: adding a bowel care sub-tab to existing pain management ordering plans, an EMR alert suggesting bowel care medication at time of ordering scheduled opioids, an EMR alert suggesting bowel care medication if no bowel care is scheduled within 24 hours after a scheduled opioid is ordered. Compare pre- and post-EMR enhancement incidence of the following in admitted cancer patients on scheduled opioid therapy with known chronic opioid therapy: inpatient use of methylnaltrexone and naloxegol, incidence of opioid-induced constipation complications (including ICD-10 code denoting stercoral colitis, fecal impaction, bowel perforation), and hospital LOS. Pending upon roll out of EMR enhancements. Quality Improvement; Management of Medical Interventions [ABSTRACT FROM AUTHOR]

1. Participants will be able to explain why the blow-hole colostomy technique might be considered in the setting of comfort-focused care. 2. Participants will be able to return to their own practice setting and discuss how aggressive interventions in comfort-focused care may align with hospice philosophy there, promoting dignity and optimizing quality of life. Patient-centered care is a core value of Hospice and Palliative Medicine. Non-traditional surgical interventions such as blow-hole colostomies may be appropriate in the setting of hospice care when in alignment with hospice philosophy and the patient's goals of care. In the event of severe large bowel obstruction, blow-hole colostomy can be used for urgent decompression. Compared to other techniques, studies show that blow-hole colostomies have shorter operative time with reduced risk of complications. A small number of retrospective studies describe the benefit of this procedure as a palliative measure for malignant large bowel obstruction, although we found no reports of patients receiving this procedure while enrolled in hospice. This case report explores the advantages of aggressive procedures as palliative measures for patients on hospice when in alignment with their goals of care. V.M. was a 54-year-old Hispanic woman with metastatic ovarian cancer who was enrolled in hospice (admission delayed by cultural norms). Her goals, heavily influenced by her cultural background, included completing a master's degree, finishing authoring a book, and spending more time with family. Her biggest fears were dying in severe pain and losing time with family. She developed severe, worsening abdominal pain; CT revealed a massive, large bowel obstruction and impending perforation with death expected within hours. Through shared decision making regarding her poor prognosis without intervention and discussion of goals of care, we decided on an emergent blow-hole colostomy. Post-operatively, she reported dramatic pain relief, stating that "it saved my life." She was discharged home with well controlled pain, enjoying an additional 6 weeks with her family, finishing her degree, and completing other important activities. While many patients must revoke hospice services for "aggressive" treatments, our hospice team made the decision to keep her on hospice throughout the admission for this procedure as it aligned with comfort-focused care rather than disease-targeted treatment. In summary, this case illustrates the place of invasive procedures, such as a blow-hole colostomy, in hospice care, when they align with hospice philosophy and the patient's goals of care. Surgical Palliative CareAdvocacy / Policy/ Regulations [ABSTRACT FROM AUTHOR]

Polypropylene mesh has been widely used in Urogynaecology for the management of prolapse and stress urinary incontinence. Growing recognition of long-term complications has led to the pause on all vaginally inserted mesh within the UK and other countries. These complications include vaginal mesh exposure, visceral perforation and chronic pain. It is important for all gynaecologists to be aware of these complications, signs, assessment and possible management options. Ultimately, a regional mesh centre should be involved in the care of these women as management if often complex. This article discusses different types of mesh, possible clinical presentations and the investigations which may be offered. Management options are outlined, however, involvement of the multidisciplinary team to provide adequate management options is essential. [ABSTRACT FROM AUTHOR]

Stercoral perforation of the colon is a rare and life-threatening condition caused by pressure necrosis due to fecal impaction. It is commonly associated with chronic constipation, particularly in patients with neurogenic bowel disorders or prolonged opioid use. However, its occurrence in the context of chronic heroin use is rarely reported. We report the case of a 40-year-old male with a 5-year history of heroin abuse who presented with diffuse abdominal pain, vomiting, and cessation of gas and stool passage for 10 days. Physical examination revealed a distended abdomen with generalized tenderness, guarding, and a rectal examination confirmed fecal impaction. Computed tomography (CT) showed massive fecal impaction in the sigmoid colon with pneumoperitoneum, indicating perforation. The patient underwent urgent exploratory laparotomy, revealing two perforations in the sigmoid colon with extensive fecal peritonitis. A segmental resection of the sigmoid colon with colostomy was performed. Postoperatively, the patient required intensive care for septic shock but eventually recovered and was referred to an addiction treatment program. This case highlights the serious gastrointestinal complications associated with chronic opioid use, particularly heroin. The pathophysiology involves opioid-induced inhibition of gastrointestinal motility, leading to chronic constipation, fecaloma formation, and subsequent perforation. Early recognition and prompt surgical intervention are crucial in managing stercoral perforation, which carries a high mortality rate if delayed. This case underscores the importance of recognizing gastrointestinal risks in chronic opioid users, especially heroin, and the need for integrated care strategies to prevent severe complications like stercoral perforation. • Stercoral perforation is a rare, life-threatening condition linked to chronic heroin use. • Heroin-induced constipation can lead to severe fecal impaction and bowel perforation. • Prompt CT imaging and surgical intervention are crucial for managing stercoral perforation. • This case highlights the need for awareness of gastrointestinal risks in opioid users. • Integrated care is vital to prevent severe complications from opioid-induced constipation. [ABSTRACT FROM AUTHOR]

Ileal perforation is a rare but serious condition that can arise from accidental ingestion of foreign objects. This report discusses an unusual case of ileal perforation peritonitis caused by ingestion of a chicken bone. A 60-year-old male presented with acute generalized abdominal pain, fever, nausea, and vomiting for three days. A physical examination revealed signs of peritonitis. Imaging results were unremarkable. Emergency laparotomy revealed perforation in the ileum caused by the chicken bone. The perforated segment was resected, and primary anastomosis was performed. Ingestion of foreign bodies, although common, rarely leads to gastrointestinal perforations. Among these foreign bodies, chicken bones are rarely reported, making the diagnosis challenging because of nonspecific symptoms and low clinical suspicion. Prompt surgical intervention is crucial for managing complications such as peritonitis and sepsis. This case highlights the importance of considering foreign body ingestion in the differential diagnosis of acute abdominal pain, particularly in patients without an obvious cause of peritonitis. Early detection and timely surgical intervention are essential to improve patient outcomes. • Ileal perforation caused by the accidental ingestion of chicken bone is an infrequent and challenging diagnosis. • Preoperative diagnosis was challenging in a 60-year-old male due to nonspecific symptoms and unremarkable imaging results. • Prompt resection and primary anastomosis led to successful management of ileal perforation and peritonitis. • This case emphasizes the need to consider foreign body ingestion in the differential diagnosis of acute abdominal pain. [ABSTRACT FROM AUTHOR]

The coexistence of visceral myopathy (VM) and Hirschsprung's disease (HD) is exceptionally rare yet clinically significant. Both conditions necessitate full-thickness biopsy for precise diagnosis. Despite potential similarities in presentation, no documented cases have established an association between these two disorders. We present a 3150-g, full-term male newborn, four days old, born without maternal pathologies or antenatal diagnoses. He was admitted to the emergency department with one day of fecal vomiting, lethargy, and decreased intake. On admission, he exhibited hypothermia, tachycardia, and his oxygen saturation was 94%. Physical examination revealed a septic, dehydrated, poorly perfused newborn with a distended abdomen and absent bowel sounds. Abdominal X-ray indicated pneumoperitoneum. Emergency laparotomy revealed colonic perforation necessitating resection and colonic anastomosis, with the abdomen left open and covered by a dressing, followed by a loop-ileostomy in the subsequent surgery. Surgical biopsies, including a later laparoscopic intestinal mapping, confirmed VM and HD. The patient progressed with complete oral feeding, normal bowel transit through the ileostomy, and no associated complications. Currently, the patient awaits resection of the aganglionic segment and rectal pull-through. This case may suggest either an incidental finding or an undiscovered common etiology linking HD and VM in neonatal intestinal perforation. Comprehensive diagnostic approaches, personalized treatments, and further exploration of their genetic and developmental connections are crucial for improving patient outcomes. [ABSTRACT FROM AUTHOR]

• GI tract perforation following RFA for liver tumors is rare but potentially fatal. • The small intestine is vulnerable to thermal injury resulting from RFA. • Patients receiving ablation for liver tumors in proximity to the small intestine require careful observation. We analyzed the incidence and mortality rate of gastrointestinal (GI) tract perforation after radiofrequency ablation (RFA) for hepatic tumors and assess its risk factors. This retrospective cohort study included 4799 patients with malignant tumors who underwent RFA (n = 7206). Sixty-nine cases of thermal injury to the GI tract were identified via a search of the electronic medical record system using index terms and divided into two groups according to the thermal injury with (n = 8) or without (n = 61) GI tract perforation based on follow-up CT reports. The risk factors for GI tract perforation were identified via multivariable logistic regression analysis using clinical, technical, and follow-up CT findings. The incidence of thermal injury to the GI tract and GI tract perforation was 0.96 % (69/7206) and 0.11 % (8/7206), respectively. The type of adjacent GI tract and history of diabetes mellitus differed significantly between the two groups (p < 0.05). The index tumor being located around the small intestine was the only significant risk factor for GI tract perforation after ablation (Odds ratio, 22.69; 95 % confidence interval, 2.59–198.34; p = 0.005 [reference standard, stomach]). All perforations were not identified on CT images immediately after RFA. The median time to detection was 20 days (range, 3–41 days). Two patients (25 %, 2/8) died due to perforation-related complications. GI tract perforation after RFA for hepatic tumors is rare; however, it is associated with high mortality. Thus, careful follow-up is required after RFA if the index tumor is located around the small intestine. [ABSTRACT FROM AUTHOR]

Foreign body ingestion is frequent in younger children, with generally good outcome on conservative management. However, magnetic beads ingestion is an exceptional cause of intestinal perforation in the older children. An 8-year-old boy presented with clinical signs of generalized acute peritonitis. Abdominal plain X-ray confirmed the foreign object in the digestive tract and oriented the etiology by highlighting several air-fluid levels, distended small bowel loops, pneumoperitoneum and the presence of a bilobed foreign body projected adjacent to the 5th lumbar vertebra. Open surgical exploration was performed and revealed a peritoneal fluid, 2 perforations in the small bowel and 2 adhered pieces of magnets. A 20 cm ileal resection, including the segment with the 2 perforations, was performed followed by a terminal ileostomy. The restoration of gastrointestinal continuity was performed 16 days later. After a follow-up of 2 years and 8 months, the patient was free of any symptom. In cases of acute peritonitis due to perforation, the general condition deteriorates progressively. Fever may be absent, as was the case with our patient. Abdominal pain is the predominant symptom, it is often accompanied by vomiting that can be alimentary, bilious, or even fecaloid and/or by cessation of bowel movements and/or gas. Abdominal rigidity is a major physical sign, sometimes replaced by generalized guarding. Ingestion of gastrointestinal foreign bodies is rare in older children, the presence of more than one magnet can lead to peritonitis due to intestinal perforation. • What is known on the subject? Intestinal perforation due to magnets ingestion is not exceptional in children. It happens when more than one magnet is ingested. However, it is not the most common etiology of acute abdomen in children. • What this study adds? Peritonitis due to intestinal perforation secondary to magnets ingestion may be confirmed only during surgical exploration in some cases. In some cases, the management may require multiple surgeries. • Open surgery is still used in developing countries [ABSTRACT FROM AUTHOR]

Background: The use of rotational atherectomy (RA) in percutaneous coronary intervention (PCI) of acute coronary syndrome (ACS) is considered relatively contraindicated. There have been several observational studies showing RA use in ACS, however, no systemic studies have been undertaken. We sought to evaluate the feasibility and outcomes of RA PCI in ACS by performing a meta-analysis.Methods: We searched PUBMED, EMBASE, CINAHL, and Cochrane Central Register of Clinical Trials for any studies that evaluated the role of RA PCI in ACS. The outcomes analyzed were all-cause mortality, cardiac mortality, short and long-term major adverse cardiac events (MACE), procedural complications and cardiac perforations.Results: There was a total of 8 retrospective studies with a total population of 1237 with a median follow up of 23 months. The median age of the included patient was 73. Angiographic success rate was 97.4%. The rate of all-cause mortality and cardiac mortality were 5% (range 1-12%, p < 0.001, I2 = 92%) and 2% (range 0-5%, P = 0.03, I2 = 58%) respectively. In-hospital MACE and long-term MACE were 7% (range 3-13%, p < 0.001, I2 = 87%) and 29% (range 21-37%, p = 0.21, I2 = 34%) respectively. The incidence of total procedural complications was noted to be 7% (range 2-14%, p < 0.001, I2 = 90%). Rate of perforation was 1% (range 0-1%, p = 0.9, I2 = 0%).Conclusion: Our results show that RA PCI is feasible in ACS with comparable procedural complications and short-term MACE, but with a higher long-term MACE rate compared to RA PCI in routine cases. [ABSTRACT FROM AUTHOR]

Kasai portoenterostomy (KPE) is the preferred treatment for biliary atresia (BA) patients. It has been shown that the center caseload of KPE impacts on native liver survival. We aimed to define the impact of KPE caseload on complications at the time of liver transplantation (LT). Retrospective data collection of LT for BA performed in our tertiary center between 2010 and 2018. The patients were grouped according to the caseload of the center that performed KPE: Group A (≥5 KPE/year) and Group B (<5 KPE/year). We analyzed total transplant time (TTT), hepatectomy time, amount of plasma and red blood cell (RBC) transfusions, occurrence of bowel perforations at LT. Among 115 patients, Group A (n 44) and Group B (n 71) were comparable for age, sex, PELD score, TTT. The groups differed for: median hepatectomy time (57 min, IQR = 50–67; vs 65, IQR 55–89, p = 0.045); RBC transfusions (95 ml, IQR 0–250; vs 200 ml, IQR 70–500, p = 0.017); bowel perforations (0/44 vs 15/71, p = 0.001). One-year graft loss in Group A vs Group B was 1/44 vs 7/71 (p = 0.239), whereas deaths were 0/44 vs 5/71 respectively (p = 0.183); 5/15 patients who had a perforation eventually lost the graft. This study found an association between KPE performed in low caseload center and the incidence of complications at LT. These patients tend to have a worse outcome. The centralization of KPE to referral center represents an advantage at the time of LT. We studied the impact of Kasai portoenterostomy (KPE) caseload on complications at the time of liver transplantation (LT), in 115 patients. We found an association between KPE performed in low caseload center and increased bowel perforations and blood transfusions. We suggest to centralize to experienced center all children requiring KPE. [ABSTRACT FROM AUTHOR]

Although patients with Rapunzel syndrome are often asymptomatic, rare complications such as isolated gastric or duodenal perforation, pancreaticobiliary or intestinal obstruction, and intussusception have been described. A 5-year-old female with no known medical history presented after nearly two weeks of worsening constipation, abdominal distension, and abdominal pain. A CT scan demonstrated a large gastric bezoar, pneumoperitoneum, and large volume complex free fluid. The patient was taken to the operating room for an abdominal exploration. We found a large gastric trichobezoar with hair extending into the small bowel, consistent with Rapunzel syndrome. The gastric trichobezoar was connected to a mid-ileal trichobezoar through interdigitating hair fibers. At multiple locations along the small bowel, garroted linear perforations had occurred due to tension created by the intestinal peristalsis along the interconnecting hair fibers, creating mucosal ulcerations and transmural pressure necrosis that required an extensive small bowel resection. Ultimately, we did one end-end small bowel anastomosis and placed a gastrostomy tube. Gastrostomy tube feeds were started on postoperative day 6 after confirming with a contrast study that there were no intestinal leaks. She developed a superficial wound infection that was managed with antibiotics and negative pressure wound therapy. She was discharged tolerating regular diet on post-operative day 23, and is undergoing psychiatric therapy. Although rare, Rapunzel syndrome can lead to severe complications. When two trichobezoars are present, interconnecting hair fibers can cause small bowel perforations. [ABSTRACT FROM AUTHOR]

Dog bites commonly result in soft tissue injuries and infections, but rarely cause intestinal perforation. A 9-year-old male presented with abdominal distension and vomiting three days after being bitten in the abdomen by a stray dog. He was not evaluated immediately after the injury. One day later he developed abdominal distension, difficulty passing stool and gas, non-projectile vomiting, and intermittent high-grade fever. Two days after these symptoms began, he visited a local health center where he was started on antibiotics and was referred to our hospital for further care. On arrival, he was febrile, tachycardic, tachypneic, irritable, had a normal oxygen saturation and a Glasgow Coma Scale of 15. Abdominal examination revealed distension, diffuse tenderness, absent bowel sounds, and visible bite marks in the left lumbar and iliac regions. Blood tests were normal. A plain abdominal X-ray showed pneumoperitoneum. Suspecting a bowel perforation, the patient was taken to the operating room for an exploratory laparotomy. Approximately 200 ml of pus were found in the peritoneal cavity, along with a pinpoint jejunal perforation 30 cm from the ligament of Treitz, and a serosal tear 3 cm distal to it. The involved jejunal segment was resected, followed by a primary end-to-end jejunal anastomosis. Oral feedings were initiated on postoperative day four. The recovery was uneventful and at the two-week follow-up, he was in good health. Intestinal perforation following a dog bite, although rare, should be considered in patients presenting with abdominal symptoms after such injuries. [ABSTRACT FROM AUTHOR]

According to the fourth revised edition of the world health organization classification of hematopoietic tumors, methotrexate (MTX)-associated lymphoproliferative disorder (MTX-LPD), an atypical pathological condition, is categorized under other iatrogenic immunodeficiency-associated lymphoproliferative disorders (OIIA-LPDs). An 80-year-old woman presented with OIIA-LPDs that simultaneously occurred in the gingiva and intestinal mucosa, causing intestinal perforation requiring emergency surgery. She was referred to our hospital because of poor wound healing after maxillary right first molar extraction. She had been prescribed MTX and prednisolone for rheumatoid arthritis and bisphosphonate for osteoporosis. We diagnosed her with medication-related osteonecrosis of the jaw, as the lesion showed bone exposure with mild redness and swelling of the surrounding gingiva and a cytological result of Class II. However, 9 months later, following the exfoliation of a partial sequestrum of the maxillary right first molar, a rapidly growing mass with gingival necrosis appeared, necessitating a biopsy. Simultaneously, abdominal pain worsened, and computed tomography revealed intestinal perforation; an emergency laparotomy was performed to remove the perforation and the surrounding ulcer-prone area. Histopathological examination of both lesions revealed diffuse large B-cell lymphomas. The final diagnosis was of MTX-LPD, as the mass, gingival necrosis, and residual small intestinal ulcer disappeared 2 months after MTX discontinuation. The exposed bone completely disappeared after 24 months, and no recurrence was noted after 60 months following MTX discontinuation. Although intestinal perforation due to MTX-LPD is extremely rare, patients with RA are immunosuppressed. Therefore, MTX-LPD must be recognized as a dangerous condition that requires careful general monitoring in such patients. [ABSTRACT FROM AUTHOR]

Background: Gastroduodenal ulcer perforation is a common abdominal emergency that may be curable without surgical repair in non-elderly patients with localized and stable symptoms. However, the outcomes of nonoperative approaches have rarely been described. Methods: Using a Japanese national inpatient database, we identified 14,918 patients with gastroduodenal ulcer perforation who were hospitalized and received nonoperative treatment from July 2010 to March 2017. We categorized these patients into three groups according to age: 18 to 64 years (young group, n=8407), 65 to 74 years (old group, n=2616), and ≥75 years (old-old group, n=3895). We investigated the characteristics, treatments, and outcomes in each group. Results: Most of the patients were men (71%), and the median patient age was 62 years (interquartile range, 47–75 years). The old and old-old groups had more comorbidities than the young group. Whereas most patients were administered proton pump inhibitors and various antibiotics (96% and 90%, respectively), only 58% of patients underwent gastric tube placement. Surgical repair >3 days after admission was performed in 7.1% of all patients (6.3% vs. 7.9% vs. 5.5%, P<0.001). The old and old-old groups showed higher mortality (1.4% vs. 8.3% vs. 18%, P<0.001) and morbidity (6.6% vs. 15% vs. 17%, P<0.001) than the young group. The median length of stay was almost 2 weeks (13 vs. 17 vs. 20 days, P<0.001). Discussion: Unlike previous studies, many patients aged >65 years received nonoperative treatment in this nationwide cohort. Our findings provide useful information for clinicians and patients hospitalized for gastric ulcer perforation. [ABSTRACT FROM AUTHOR]

Bowel obstruction patients are at increased risk of emergency surgery and have poor nutritional and physical conditions. These patients could benefit from prehabilitation and prevention of emergency surgery. This study assessed the effect of a multimodal obstruction treatment for bowel obstruction patients in colorectal surgery on the risk of emergency surgery and postoperative morbidity and mortality. This multicenter observational cohort study included all consecutive bowel obstruction patients who received obstruction treatment (obstruction protocol) in the period 2019–2020 in two Dutch hospitals. Benign and malignant causes of bowel obstruction were included. Treatment consisted of 1. dietary adjustments, 2. postponing surgery for three weeks, 3. laxatives, and 4. prehabilitation. We compared emergency surgery and postoperative morbidity and mortality rates to known rates from the literature. Eighty-nine patients were included: obstruction treatment was successful in 77 patients (87%) who underwent elective surgery and unsuccessful in 12 patients (13%) who underwent emergency surgery. Sixty-six (74%) had colorectal cancer, and 22 (25%) had benign disease. Thirty-day mortality of 0% in our study was significantly lower than the national average of 4% in colorectal cancer patients in the Netherlands (p = 0.049). Anastomotic leakage rate was 3%, severe complications (Clavien-Dindo ≥ III) 8%, and bowel perforation 0%. These rates did not differ significantly from rates reported in literature. The obstruction treatment prevented emergency surgery in most patients with bowel obstruction and reduced postoperative morbidity and mortality. The obstruction treatment seems to be a safe and efficient alternative to emergency surgery. [ABSTRACT FROM AUTHOR]

The purpose of the study was to determine the incidence of uterine perforations, review the associated complications, and propose guidelines for management of perforations after brachytherapy. A retrospective chart review was conducted for all patients with cervical cancer who received single or multiple high-dose-rate brachytherapy implants between April 2006 and May 2017 at a single academic institution. CT and MRI images were retrospectively evaluated to record incidences of uterine perforation of tandem during brachytherapy. Acute and long-term complications during and after treatment were scored using the Common Terminology Criteria for Adverse Events, Version 4.0, of the National Cancer Institute. A total of 123 patients were included in the study. Perforations were observed in 22 patients (17.9%) with 31 (6.4%) of the 482 total implants. Of the different categories of adverse events, only the rate of acute infectious complications among those with perforations (n = 3, 13.6%) versus those without perforations (n = 3, 3.0%) was significant (p = 0.040). Two of the three perforated patients with acute infections had mild urinary tract infections, and all resolved without complications or treatment delays. The remaining one patient had a frank perforation of the anterior uterine wall with a subsequent Grade 3 pyometra infection despite administration of prophylactic antibiotics and 1-week treatment delay. This case was eventually resolved with cervical dilation and evacuation of fluid. Long-term complications were not different between the two arms. Patients with cervical cancer with uterine perforations may be able to safely proceed with brachytherapy treatment without delay or need for prophylactic antibiotics in the acute setting. Further validating data would be able to assist in establishing a new standard of care and help prevent unnecessary and harmful breaks during treatment. [ABSTRACT FROM AUTHOR]

Coronary artery perforation (CAP) is a rare but potentially life-threatening complication of percutaneous coronary intervention (PCI), however if recognized and managed promptly, its adverse consequences can be minimized. Risk factors for CAP include the use of advanced PCI technique (such as atherectomy and chronic total occlusion interventions) and treatment of severely calcified lesions. There are 3 major types of CAP depending on location: (a) large vessel perforation, (b) distal vessel perforation, and (c) collateral perforation. Large vessel perforation is usually treated with implantation of a covered stent, whereas distal and collateral vessel perforations are usually treated with coil or fat embolization. In this article we provide a state-of-the-art overview of the contemporary management of CAP. [ABSTRACT FROM AUTHOR]

Obstructed hemivagina with ipsilateral renal agenesis (OHVIRA) is a rare congenital Müllerian anomaly presenting in female adolescents with progressive pelvic pain, dysmenorrhea, and/or vaginal bulge due to the development of hematocolpos in the obstructed hemivagina. This case describes a unique presentation of OHVIRA in a pregnant adolescent with spontaneous vaginal septum perforation. It emphasizes important considerations for pregnancy and abortion care in those with underlying Müllerian anomalies. A 17-year-old G1P0010 healthy female presented to the pediatric and adolescent gynecology clinic for prolonged vaginal bleeding. Two months prior, she had a missed abortion at 13 weeks' gestation and presented to an outside hospital where she was noted to have retained products of conception protruding from a lateral defect in the vaginal wall. This was an unexpected finding. She underwent a suction dilation and curettage from site of the spontaneous vaginal septum perforation. She was referred to pediatric and adolescent gynecology due to concerns for atypical anatomy. She was unable to tolerate an in-office pelvic exam. Pelvic ultrasound noted fundal indentation with the septum extending to the cervix. Pelvic MRI noted an absent left kidney, two separate uterine horns diverging at the level of the fundus with two cervices consistent with OHVIRA. No hematocolpos was noted. Renal ultrasound confirmed solitary right kidney. She underwent vaginoscopy under anesthesia which demonstrated an obstructed left vaginal septum with a 1.2 cm perforation. Excision of vaginal septum was performed. Following resection of the septum, 2 cervices was noted consistent with a didelphys uterus. The patient made an uncomplicated recovery. Patients with reproductive tract anomalies who undergo procedural termination of pregnancy are at increased risk of complications, including uterine perforation, adhesion formation, and repeat attempts at termination. There are few reports on procedural abortions in patients with uterine anomalies and even fewer for patients with OHVIRA. In pregnant individuals with OHVIRA, a missed abortion can present similarly, and microperforation of the obstructed vaginal septum may result in retained products of conception, necessitating further intervention. There may be utility to consider medical means first to induce abortion in patients with suspected Müllerian anomalies. If surgical evacuation is considered, a good understanding of possible Mullerian anomalies and ultrasound guidance may increase success of the procedure and decrease incidence of retained products of conception and uterine perforation in those with a uterine anomaly. [ABSTRACT FROM AUTHOR]

Locally advanced rectal cancer (LARC) is commonly managed with neoadjuvant chemoradiation (neoCRT) followed by surgery, though not without complications. The anatomical exposure of the colon and rectum and pelvic radiotherapy poses risk, with rectal perforation and bowel obstruction, though rare, carrying life-threatening potential. This case highlights an exceptionally rare occurrence of concurrent rectal perforation and rectal obstruction in a 77-year-old male with LARC, just two months post neoCRT. Initial symptoms included rectal bleeding, and diagnostic procedures confirmed rectal T1N3adenocarcinoma with no metastasis. Emergency admission, prompted by complete bowel obstruction symptoms, led to discovery of rectal perforation during laparotomy, sealed by the bladder. Pathological analysis attributed the cause to radiation proctitis, reporting complete response to neoCRT with no residual tumor. The rarity of both bowel obstruction and perforation as neoCRT complications, particularly in the acute phase of radiation proctitis, is noteworthy in this case. The absence of tumoral cells at the affected sites emphasizes the exceptional nature of this case. This case underscores the importance of recognizing acute post neoCRT injuries as potentially life-threatening complications, emphasizing the need for heightened awareness and consideration in clinical management. • Locally advanced rectal cancer (LARC) is commonly managed with neoadjuvant chemoradiation followed by surgery. • The colon and rectum, due to their anatomical locations, are commonly impacted during abdominal and pelvic radiotherapy. • Damage to the rectal epithelium, termed "Radiation proctopathy", occurs as a result of ionizing radiation therapy. • Radiation proctitis is classified based on the time from the initiation of RT to the developement of the signs and symptoms. [ABSTRACT FROM AUTHOR]

Recurrent pyloric stenosis poses unique diagnostic challenges, particularly in discerning authentic recurrence from post-pyloromyotomy scarring on ultrasound imaging. A male infant began experiencing projectile non bilious vomiting nine days following birth. Upon initial clinical examination, no evidence of pyloric olive or signs of dehydration were detected. However, an abdominal ultrasound examination unveiled a thickened pyloric wall measuring 4.5 mm, along with a pyloric canal length of 17 mm, indicating the presence of pyloric stenosis. Consequently, an uncomplicated supra-umbilical open pyloromyotomy was performed when the patient was 20 days old. Twenty-three days after being discharged, the patient presented to the emergency for a 24-h history of vomiting after every third bottle. On physical exam, a palpable pyloric olive was discovered. The patient had gained 410 g in 23 days (about 18 g/day). An abdominal ultrasound showed a pyloric muscle length of 21 mm and a muscle thickness of 4.5 mm. A multidisciplinary reunion was conducted between the pediatric gastroenterology and pediatric surgery department deciding to perform a second pyloromyotomy. This was executed through the same supra-umbilical incision. A healed incision scar was found along the complete length of the pyloric muscle on the anterior side. The decision was made to perform a second pyloromyotomy approximately 5 mm more dorsal from the first myotomy. There was a small perforation of the mucosa on the duodenal side which was sutured with a PDS 6/0. The progression unfolded without incident, with an improvement in symptoms and weight gain. Follow-up ultrasounds showed a gradual decrease in the length of the pyloric muscle. Recurrent pyloric stenosis is challenging to differentiate from postoperative edema. Particularly, the pyloric length on ultrasound can help distinguish and indicate whether a second pyloromyotomy should be performed or not. [ABSTRACT FROM AUTHOR]

Hemolytic uremic syndrome (HUS) usually presents with mild gastrointestinal symptoms, typically managed medically. We describe 3 patients with challenging clinical presentations diagnosed with colonic perforation, review the literature, and discuss lessons learned. Case 1 : A 5-year-old girl presented with symptoms of HUS. Three weeks later, with new fevers and tachycardia, computerized tomography (CT) revealed pneumoperitoneum. She underwent resection of necrotic small bowel and sigmoid, with a second look resection and creation of multiple stomas. After 5 months, she was discharged on total parenteral nutrition (TPN) and hemodialysis. She later had restoration of intestinal continuity and renal transplantation. A 2-year-old boy with HUS underwent, over 3-weeks, 9 ultrasounds, percutaneous ascites aspiration, and 2 CT scans before diagnosis of colonic necrosis and perforation. A laparotomy revealed necrotic colon with a thick rind encasing the bowel, rendering full exploration and stoma creation impossible. Drains were placed, and he was discharged on TPN after 2 months. He underwent colo-colonic anastomosis and a TPN wean after one year with full renal recovery. A 3-year-old boy with HUS developed worsening distension. After one week, he suffered cardiopulmonary arrest and CT showed bowel hypoenhancement. He underwent resection of necrotic colon with transverse colostomy creation. After 4 months, he was discharged on hemodialysis. He underwent subsequent colostomy closure and renal transplantation. Bowel ischemia is difficult to diagnose in HUS. CT with intravenous contrast is critical for diagnostic accuracy. Frequent re-evaluation by pediatric surgery is important to avoid missing a surgical emergency. [ABSTRACT FROM AUTHOR]

The incidence of pediatric button battery (BB) ingestions has increased in recent years with a subsequent rise in secondary esophageal injuries. There is a paucity of published literature on the evaluation and management of acquired trachea-esophageal fistulas (TEF) in this context and therefore, the purpose of this paper was to summarize a case and propose an evidence-based protocol for acquired TEF management. A 15-month-old female presenting with fever, mild tachypnea and lethargy underwent a chest x-ray which demonstrated a BB in the upper thorax. Laryngoscopy, and subsequent rigid esophagoscopy, identified the BB in the proximal esophagus. There was surrounding inflammation and liquefactive necrosis, and the BB was removed via rigid esophagoscopy. A post-procedure chest computerized tomography following BB removal revealed a small collection in the mediastinum consistent with full thickness esophageal perforation as well as mediastinitis. She was treated conservatively and on post-operative day (POD) 7, a swallow study demonstrated no evidence of leak or stricture, thus a trial of oral, clear fluids took place. A next-day repeat swallow study was performed and revealed an acquired TEF. She was treated conservatively with proton pump inhibitor and nasojejunal feeds. Bronchoscopy, upper gastrointestinal endoscopy and repeat esophagram at six-weeks demonstrated resolution of the TEF. Clinicians should have a high index of suspicion for BB ingestion complications, even after removal. This case illustrated that patients with acquired TEF can be managed conservatively. Following literature review and our personal experience in this single case, we propose a suggested algorithm for management of these patients. [ABSTRACT FROM AUTHOR]

Appendicitis is rare in young infants and often not timely recognized due to non-specific symptoms. We aimed to increase awareness and contribute to current knowledge by presenting two cases. Case 1 ; a term boy presented at ten weeks of age with fever, vomiting and an enlarged translucent erythematous scrotum. The latter was interpreted as hydrocele and antibiotic treatment for suspicion of sepsis without patent source was started. Five days later, he developed abdominal distension and was transferred to our tertiary referral center. Imaging showed local pneumoperitoneum on ultrasound, and a covered intestinal perforation was suspected. Antibiotics were continued, obtained blood cultures were positive for Clostridium tertium. On day eight, ultrasound identified a tubular structure in the right lower quadrant. At laparotomy we found an interloop abscess in connection with the appendix and performed an appendectomy. The postoperative course was complicated by an intra-abdominal abscess, treated with antibiotics, with uneventful recovery thereafter. Case 2 ; a preterm girl (gestational age 24 weeks) developed abdominal distension at 11 days of age due to pneumoperitoneum. Laparotomy showed perforated appendicitis and a fibrinous exudate on the sigmoid. An appendectomy was performed, and a protective split ileostomy was created as a micro-perforation could not be excluded. The postoperative course was complicated by recurrent peristomal bullous impetigo and septic thrombophlebitis requiring antibiotic treatment, with uneventful recovery thereafter. Both cases underline that clinicians should include appendicitis in the differential diagnosis of young infants presenting with unexplained sepsis and/or gastrointestinal symptoms, despite the rare incidence. [ABSTRACT FROM AUTHOR]

Background: Endotracheal intubation is an essential basic skill for emergency physicians. The procedure can cause complications that should be recognized. Awareness and early identification of complications are needed to allow early intervention to optimize outcomes. The risk factors for tracheal perforation during intubation are typically related to the physician skill and experience and to the patient's comorbidities, including body habitus and chronic use of certain medications.Case Report: We report a case of a 45-year-old man with renal transplant on tacrolimus and prednisolone for 16 years. He presented with decreased level of consciousness due to an acute intracranial hemorrhage and was intubated for airway protection. Post intubation, a significant subcutaneous emphysema was noted on the patient's neck and chest, which was subsequently determined to be caused by a tracheal perforation. The management of tracheal injury depends on the size and location of the tear, as well as the patient's clinical status and comorbidities. In this case, the tracheal perforation was treated conservatively and was successful. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case has been reported to increase awareness about this rare and potentially life-threatening event. The prevention of this rare injury can be difficult but use of a slightly smaller endotracheal tube in a high-risk patient can be of benefit. In addition, early consideration of this complication when there is an acute change in physiologic status will allow for rapid facilitated management. [ABSTRACT FROM AUTHOR]

Antenatal magnesium sulfate is widely used as a tocolytic, for maternal seizures, and for seizure prophylaxis in preeclampsia. Recent studies have suggested that antenatal magnesium sulfate use is associated with favorable neurodevelopmental outcomes in preterm infants. However, there are concerns regarding the effects of antenatal magnesium sulfate on neonates, especially regarding gastrointestinal morbidities. This study aims to explore the effects of antenatal magnesium sulfate on intestinal morbidities requiring surgery in preterm infants. This was a retrospective cohort study of 181 preterm infants who were born at less than 28 weeks of gestational age. Subjects were categorized as infants exposed to antenatal magnesium sulfate and those not exposed to antenatal magnesium sulfate. Antenatal magnesium sulfate was associated with a decreased risk of surgical conditions of the intestine (OR 0.393, 95% CI 0.170–0.905). The multivariate analysis showed that the duration of antenatal magnesium sulfate use was associated with surgical conditions of the intestine (adjusted OR 0.766, 95% CI 0.589–0.997). In the <26 weeks of gestational age subgroup, the use of antenatal magnesium sulfate was significantly associated with decreased intestinal morbidities requiring surgery (adjusted OR 0.234, 95% CI 0.060–0.922). Antenatal magnesium sulfate use appears to have a protective effect on intestinal morbidities requiring surgery in preterm infants in a duration-dependent manner. Association of antenatal magnesium sulfate use and decreased intestinal morbidities requiring surgery was more distinct in preterm infants <26 weeks of gestational age. [ABSTRACT FROM AUTHOR]

Gastrointestinal carriage of multidrug resistant (MDR) Gram-negative bacilli, especially Klebsiella pneumoniae and Escherichia coli , was highly associated with severe nosocomial infections. The main objectives of this study were to determine the clonal relatedness of intestinal carriage and transmission risk factors of MDR E. coli and K. pneumoniae amongst preterm infants admitted to the neonatal intensive care unit (NICU). A prospective cohort study of preterm infants with gestational age < 37 weeks was conducted in the NICU of the University of Malaya Medical Centre (UMMC). Infants' stool specimens were collected on day 1 (meconium), week 1, week 2, week 8 and week 10 during their admission (from 1st June to 31st August 2017) until discharge. The presence and antibiotic resistance pattern of MDR E. coli and K. pneumoniae were determined. Strain clonality and relatedness were explored via pulsed-field gel electrophoresis (PFGE) fingerprints. The risk factors for MDR strains acquisition were evaluated using the Cox proportional-hazards model and Firth logistic regression. A total of 139 stool specimens were obtained from 50 subjects. Twenty-six (52%) infants were colonized with MDR K. pneumoniae and/or E. coli. High clonal dissemination between two clusters of ESBL-producing K. pneumoniae strains was seen from PFGE profile. We detected a persistent, dominant, aminoglycosides-resistant strains cluster (cluster B), which harbored bla TEM , bla SHV , bla OXA-1 , bla CTX-M-1 , ompK35 and ompK36 genes. Infants born to women who were anemic in pregnancy [OR = 0.01 (CI = 0.00–0.39), P -value = 0.042] and infants exposed to penicillin/β-lactams group antibiotics during the first week of life [OR = 0.02 (CI = 0.02–0.32), P -value = 0.013] were found to have a lower risk of MDR K. pneumoniae and E. coli colonization. The prevalence of dominant aminoglycosides-resistant strains cluster in the NICU is alarming. Awareness of and vigilance for the dominant cluster found will enable the reduction of cross-transmission amongst high-risk infants. [ABSTRACT FROM AUTHOR]

The treatment of intestinal perforation caused by the SBC enters the small intestine in elderly patients is a challenge for urologists. The report is to share our experience of conservative treatment after a 90-year-old male with the suprapubic bladder catheter enters the small intestine. Because of the device was obstructed, a 90-year-old male went to our hospital with his family and requested to replace the SBC. When the fistula tube was replaced, it entered the intestine through the intestinal injury site instead of entering the bladder. During the hospitalization, the patient was given supportive treatments and the SBC was dynamically monitored daily and it was intermittently withdrawn out during this period. After the drainage volume was less than 10 mL for three consecutive days and the intestinal fistula was healing gradually, the catheter was taken out. According to our experience, the common complications in the process include failure to pull out the SBC, abnormal position of the SBC, and poor drainage of the SBC. However, the drainage tube placing into the small intestine through the original hole of the suprapubic bladder fistula during the replacement process is quite rare. When elderly patients have traumatic small bowel perforation, the diagnosis and treatment of intestinal perforation in elderly patients was particularly important. The conservative treatment of intestinal perforation is suitable for elderly patients who are unsuitable or unwilling to undergo a surgical operation. Of course, it should be in accordance with the patient's condition to make the right choice of treatment. [ABSTRACT FROM AUTHOR]

Background: Primary intestinal lymphomas (PILs) are rare, and this study compared the clinical outcomes of aggressive primary intestinal B-cell lymphomas (aB-PILs) and T/natural killer-cell lymphomas (T/NK-PILs).Methods: The clinical information of patients diagnosed with aggressive PILs at our institution between 1995 and 2015 were retrospectively investigated. Pathological subtypes were confirmed according to the 2016 revision of the World Health Organization classification. The correlation between clinicopathological features and overall survival (OS) was determined using univariate and multivariate analyses.Results: Cases of T/NK-PILs had higher initial bowel perforation incidence (67% vs. 7%, P < 0.001) and lower complete response rate to first-line chemotherapy regimens (22% vs. 69%, P = 0.009) than aB-PILs. Patients with aB-PILs had a better 5-year event-free survival rate (55.8% vs. 13.9%, P = 0.026) and a 5-year OS rate (74.3% vs. 29.6%, P = 0.036) than those with T/NK-cell lymphomas. Multivariate analysis identified that female gender and stage III/IV were unfavorable prognostic factors. Among the 54 patients with diffuse large B-cell lymphoma (DLBCL), those with International Prognostic Index (IPI) scores of 0-2 had a better 5-year OS rate than those with scores of 3-5 (84.2% vs. 46.8%, P = 0.002). IPI scores of 3-5 (P = 0.026) and tumors located in the large intestine (P = 0.015) were poor prognostic factors based on the multivariate analysis.Conclusion: The prognosis of T/NK-PILs was less favorable than that of aB-PILs. Female gender, stage III/IV disease, DLBCL with IPI scores of 3-5, or tumors in the large intestine were poor prognostic factors. [ABSTRACT FROM AUTHOR]

Objectives: Updated estimates of the prevalence of complications and case fatality ratio (CFR) among typhoid fever patients are needed to understand disease burden.Methods: Articles published in PubMed and Web of Science from 1 January 1980 through 29 January 2020 were systematically reviewed for hospital or community-based non-surgical studies that used cultures of normally sterile sites, and hospital surgical studies of typhoid intestinal perforation (TIP) with intra- or post-operative findings suggestive of typhoid. Prevalence of 21 pre-selected recognized complications of typhoid fever, crude and median (interquartile range) CFR, and pooled CFR estimates using a random effects meta-analysis were calculated.Results: Of 113 study sites, 106 (93.8%) were located in Asia and Africa, and 84 (74.3%) were non-surgical. Among non-surgical studies, 70 (83.3%) were hospital-based. Of 10,355 confirmed typhoid patients, 2,719 (26.3%) had complications. The pooled CFR estimate among non-surgical patients was 0.9% for the Asia region and 5.4% for the Africa region. Delay in care was significantly correlated with increased CFR in Asia (r = 0.84; p<0.01). Among surgical studies, the median CFR of TIP was 15.5% (6.7-24.1%) per study.Conclusions: Our findings identify considerable typhoid-associated illness and death that could be averted with prevention measures, including typhoid conjugate vaccine introduction. [ABSTRACT FROM AUTHOR]

Abdominal pelvic radiation therapy can induce acute or chronic lesions in the small bowel wall, called radiation enteritis. Treatment of acute radiation enteritis is essentially symptomatic; symptoms regress when radiation is discontinued. Conversely, late toxicity can occur up to 30 years after discontinuation of radiation therapy, posing diagnostic problems. Approximately one out of five patients treated by radiation therapy will present clinical signs of radiation enteritis, including obstruction, malabsorption, malnutrition and/or other complications. Management should be multidisciplinary, centered mainly on correction of malnutrition. Surgery is indicated in case of complications (i.e., abscess, perforation, fistula) and/or resistance to medical treatment; intestinal resection should be preferred over internal bypass. The main risk in case of iterative resections is the short bowel syndrome and the need for definitive nutritional assistance. [ABSTRACT FROM AUTHOR]

Post-transplant lymphoproliferative disorder (PTLD) comprises a broad spectrum of diseases and is a rare but serious complication of solid organ transplantation. We report the case of a 45-year-old simultaneous pancreas and kidney (SPK) transplant recipient with diffuse, early-onset PTLD, manifesting as jejunal perforation at 6 months after transplantation. The patient underwent urgent small bowel resection of the affected portion of jejunum. The surgical pathology report was significant for diffuse large B-cell lymphoma. Subsequently, the patient underwent a full workup, including upper and lower endoscopy and whole-body positron emission tomography that revealed involvement of the axial skeleton and multiple abdominal organs with sparing of the grafts. He was treated with rituximab and intrathecal methotrexate for central nervous system prophylaxis. The patient experienced complete resolution of disease by positron emission tomography 8 months after initial presentation. We found no previous report in the literature of intestinal perforation as the initial presentation of PTLD in SPK transplant recipients. [ABSTRACT FROM AUTHOR]

• Rectal barotrauma is a rare pathology that need a multidisciplinary approach. • Laparoscopic surgery is feasible approach in colonic injuries due to barotrauma. • Delaying its diagnosis and management has critical consequences for this type of patient. In the XIX century, the surgeon faces surgical challenges due to the creation of new technologies. Accidental or compressed air-induced injury to the colon and rectum is rare. We present the case of a 45-year-old patient who consults the emergency department, then a high-pressure rectal pneumatic trauma, with clinical findings of peritonism, managed with a Hartmann-type colostomy. and anterior resection of the rectum using laparoscopy, with findings of rectosigmoid perforation. With this, it can be demonstrated that minimally invasive surgery is a feasible approach in hemodynamically unstable patients without contraindication for pneumoperitoneum. [ABSTRACT FROM AUTHOR]

To date, there appear to be only four documented cases of jejunal perforation and all were in patients with HIV.[3] This appears to be the first reported case of jejunal perforation secondary to disseminated histoplasmosis in an immunosuppressed, non-HIV-infected patient. A 41-year-old male with known rheumatoid arthritis-associated bronchiolitis presented with 1 week of fever, shortness of breath, worsening productive cough, night sweats, and a new oral lesion. Additionally, histoplasma antigen was detected in the patient's urine and a biopsy of the patient's oral lesion also showed disseminated histoplasmosis. [Extracted from the article]

Colonoscopy is the most sensitive and specific test for detecting colon cancer and is a common procedure performed in over 19 million people annually in the United States as of 2017. Though the incidence of complications from colonoscopy is low, there are several important complications that may require surgical intervention including bowel perforation, bleeding, splenic injury, and diverticulitis. Post-polypectomy coagulation syndrome (PPCS) is an uncommon complication of colonoscopy however, clinical presentation mimics bowel perforation and the differentiation between the two is vital as the management differs. Herein we present a case of a 43-year-old female with abdominal pain after undergoing colonoscopy and developed PPCS. • Post-polypectomy coagulation syndrome is a rare complication following colon polypectomy using electrocauterization. • Patients with abdominal pain after colonoscopy should be evaluated with cross-sectional imaging to rule out perforation. • Focal mural wall thickening with surrounding fat infiltration and absence of extraluminal air are imaging hallmarks of PPCS. [ABSTRACT FROM AUTHOR]

The ingestion of multiple magnets may lead to severe complications including bowel obstruction, perforation, fistula, peritonitis, short bowel syndrome, life-threatening injuries, and even death. The annual case number of high-powered neodymium magnets ingestion has been increasing in the western world and the dearth of available data demonstrates that this issue has been neglected in Taiwan. We searched the electronic medical records of our institution for patients younger than 18 years old who were diagnosed with, who had ever visited our emergency department, or been hospitalized for magnetic foreign body ingestion between January 2009 and March 2018. Demographic data including the number, shape, and size of magnets ingested, the clinical presentation, type of intervention, and complications were reviewed. Thirteen patients who met the enrollment criteria were analyzed. One patient was documented between 2009 and 2013, and twelve were documented between January 2014 and March 2018. Five of the cases documented between 2014 and 2018 had ingested Buckyballs. The median age of the patients was 5 years. All of the patients with clinical symptoms had ingested more than one magnet and required endoscopic or surgical intervention. Bowel perforation or deep ulcer with impending perforation was found in three patients during surgery. The number of children who visited our emergency department or were hospitalized due to the ingestion of magnets has increased recently. The presence of high power of neodymium magnets in many products increases the risk of ingesting multiple magnets resulting in serious complications. Therefore, stricter policies are needed to prevent children from obtaining products that contain magnets. [ABSTRACT FROM AUTHOR]

The ingestion of multiple magnets is harmful in children because it can cause intestinal obstruction and/or perforation. We present an approach for the management of children visiting the emergency department with multiple magnet ingestion. We retrospectively investigated 9 children who presented to 2 centers in Korea between January 2004 and August 2018 with a history of multiple magnet ingestion. Demographics, major symptoms, management, and outcomes were analyzed. Of the 9 children investigated, median age was 34 months with vomiting and abdominal pain as the most common initial symptoms. Six (67%) underwent surgical removal of the magnets after observing for mean 2.2 days. Reasons for surgical managements were no magnet migration on serial radiographs in 3, suspected obstruction or microperforation in 2 and failed endoscopic removal in 1. Three patients (33%) were asymptomatic and were treated with meticulous observation using serial plain radiographs for average 3.3 days. All patients discharged without adverse outcomes and complications. Surgical removal is warranted in patients with symptoms suspicious of intestinal obstruction and/or perforation or without magnet migration. Asymptomatic children can be observed over at least 2–3 days with serial simple radiographs while awaiting magnet migration. IV. [ABSTRACT FROM AUTHOR]

Introduction: Although levodopa/carbidopa intestinal infusion (LCIG) proved a sustained efficacy on Parkinson's disease (PD) motor fluctuations, there is a lack of studies on mortality of LCIG patients. In this study, we aimed at analyzing mortality and its predictors in a cohort of 105 PD patients treated with LCIG for over 10 years.Methods: The death rate, death causes, mortality predictors, and serious adverse events (SAEs) were analyzed. A Cox regression model was used to estimate the influence of several demographic and clinical factors on mortality, and a binary logistic regression to evaluate the association between SAEs number and mortality. Kaplan-Meier and Log-rank test was used for a survival comparison between patients with an early drop-out (within 3 years since LCIG start) and patients continuing LCIG.Results: Ninety-eight advanced PD patients treated with LCIG were included. During follow-up, 34.7% of patients died at a mean age of 74.7 years, with a mean survival time of 4.6 years since LCIG start and 18 years since PD onset. The only predictor of mortality identified was the Mini Mental State Examination score at LCIG start (p:0.034). A total of 222 SAEs occurred in 87.9% of LCIG patients. The number of SAEs did not correlate with the mortality of LCIG patients (p:0.370). No survival difference exists between early drop-out patients and those continuing LCIG (p:0.341).Conclusion: Our findings do not indicate an association between SAEs or LCIG treatment duration and mortality and highlight the importance of cognitive alterations as a mortality predictor of LCIG patients. [ABSTRACT FROM AUTHOR]