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Diaphragmatic rupture due to blunt trauma is well recognised though uncommon. Most cases are diagnosed at the time of injury, but a proportion remain undiagnosed, only to present some months or even years later. This "delayed" group can present in a number of ways, including chronic abdominal and chest problems or an acute crisis. Herniation of abdominal viscera is the most common sequel, with strangulation and gangrene as the most serious complication. This paper reports a case of delayed presentation of diaphragmatic rupture and herniation presenting as tension hydropneumothorax due to small bowel perforation. A short discussion addresses the problems in diagnosis of this condition. We believe this to be the first reported case of perforated small bowel leading to tension hydropneumothorax.

We report one case of biopsy-proved large cell arteritis with polyneuropathy and intestinal involvement leading in 15 days to mesenteric ischemia, small bowel perforation, multivisceral failure and death in spite of the administration of high-dose steroids, symptomatic treatment and abdominal surgery.

This report deals with the first 350 laparoscopic cholecystectomies performed at Creighton University, beginning in October 1989, by one of the authors (R.J.F., Jr.). An open technique was used for initial access to the abdominal cavity in 343 patients (98%). Patients included 274 females and 76 males, with an average age of 45.5 years. Weight ranged from 72 to 316 pounds (32-142.2 kg). The laparoscopic procedure was successfully completed in 338 (96.6%). Operative cholangiography was performed in 113 (32.3%), and 52 (14.7%) had acute cholecystitis as determined by the final pathological report. Median operating time was 80 min. There was no operative mortality. Bile duct injury was not seen. Postoperative complications occurred in 21 patients (6%), only two of which were directly related to the open technique (cellulitis of the umbilical wound requiring antibiotics). A third patient (0.3% of 343 successful laparoscopies) required reoperation on postoperative day 4 for a small bowel perforation; the exact cause could not be determined, but conceivably it was related to the umbilical minilaparotomy. We conclude that the open technique is safe and effective method for initial peritoneal access prior to laparoscopic cholecystectomy.

During the last 10 years, 35 cases of perforation of the small bowel were treated. 16 cases (45.7%) were due to post operative adhesive ileus, 10 (28.6%) to abdominal trauma and 4 (11.4%) to inguinal or femoral hernia. Operative mortality was 17.1%. Thirty-six hours after operation, mortality was 4.3%, but over 36 hours mortality was elevated to 41.7%. In cases of small bowel perforation due to abdominal trauma and hernia, operations were undertaken sooner than in cases of perforation, due to adhesive ileus. In these cases, prognosis was good. On the other hand, all cases of small bowel perforation due to malignant tumor and mesentery arterial thrombosis died within 30 days of operation; thus the prognosis of these cases was extremely poor. Abdominal free air, leucocytosis (over 10, 000) and muscular defense were decisive factors in undertaking operation. Leucocytosis was found in 51.4% of all cases, and abdominal free air in only 34.3%. On the other hand, muscular defense was found in 85.7%, so that it was necessary to observe the patient's condition, espcially abdominal signs, carefully.

Despite the vague presentation of gastric and small bowel lymphoma, survival can be achieved by adequate surgical resection of stage I disease. A role still exists for debulking of advanced stage disease by surgical excision. Debulking enhances potential for complete response with chemotherapy, decreases the risk of gastric and small bowel perforation with large exophytic tumors as they necrose with chemotherapy, and prevents gastrointestinal obstruction from limiting patients' ability to receive chemotherapy. All attempts should be made to maintain nutritional support of these patients to allow them an adequate chance of receiving chemotherapy. The increasing frequency of immunodeficiency disorders will continue to produce higher numbers of patients with non-Hodgkin's lymphoma. Awareness of our surgical limitations is important because surgical exploration is frequently the first step. Multimodality therapy of gastric and small bowel lymphoma offers the best chance for successful outcome. Surgical resection should not prevent patients from receiving a complete trial of chemotherapy and radiation if appropriate.

Fourteen patients with primary carcinoma of the cervix and 1 patient with recurrent carcinoma received extended field irradiation because of lymphangiographic evidence of para-aortic nodal metastases. After a minimum follow-up of 24 months, 6 of 15 patients survived with no evidence of disease and 1 survived with disease. Five patients developed major bowel complications and 1 patient died from small bowel perforation probably caused by the radiation treatment. The morbidity of extended field irradiation was high when the radiation dose was more than 4500 rads in 5 weeks to the para-aortic lymph nodes.

Medical records and computed tomographic (CT) scans of 83 patients with upper abdominal trauma were retrospectively reviewed to determine errors in diagnosis using CT. Patients with possible pancreatic injury, small bowel perforation, or injury to an occult malignancy represented the most difficult diagnostic cases. A false-positive diagnosis of pancreatic injury occurred in seven of 77 patients (9%) and represented the most frequent error in the series. In three patients with subsequently surgically proved small bowel perforation, one duodenal and two proximal jejunal, the injuries were not correctly diagnosed on CT scans. In retrospect, positive CT findings were present in the case of duodenal rupture. Additionally, in two patients, duodenal rupture was suspected based on CT findings of extraluminal gas and fluid near the duodenum, but both cases were proved normal at surgery. The series included three patients with trauma involving unsuspected tumors in the liver, kidney, and stomach.

A patient who developed clostridial infection of the abdominal wall following laparotomy for small bowel perforation is described. Immediate debridement resulted in the loss of the entire abdominal wall. Dressing of the exposed viscera during the period of stabilization and prior to reconstruction was achieved using amniotic membranes.

Percutaneous nephrolithotomy is usually carried out with minimal morbidity and few perioperative complications. Despite the close proximity of the lung and bowel, injury to these adjacent organs is...

Schönlein-Henoch purpura (SHP) continues to present diagnostic and therapeutic challenges to internists and to surgeons. Indications for operation in this entity are solely for intussusception, ischemic bowel necrosis, and frank bowel perforation. We present two recent cases of spontaneous small bowel perforation in SHP and analyze the previously reported cases. Spontaneous intestinal perforation is often heralded by increase in rectal blood loss, even frank melena, and a worsening or unresponsive abdominal picutre such as progressive distention and loss of bowel sounds. Perforations, usually ileal, may be accompanied by intussusception.

Crohn病の経過中に小腸穿孔をきたした小腸型および小腸・大腸型のCrohn病の2例を経験した.症例1は34歳男性でCrohn病にて5カ月前より治療を受けていたが,突然,下腹部痛が出現して来院した.胸部単純レ線検査にて右横隔膜下に遊離ガス像を認め腸穿孔による汎発性腹膜炎として穿孔部を含め罹患部小腸を切除した.症例2は22歳男性で突然の腹痛を主訴として来院した.筋性防御,白血球増多を認め緊急手術を施行した.術中所見よりCrohn病による小腸穿孔として穿孔部を含め罹患部小腸を切除した.以上の症例について,その病理学的特徴と臨床像との関係,腸管穿孔発生の病態さらに病態に適した外科療法について検討した.その結果,穿孔部を含めて罹患部腸管を可及的に切除する術式が妥当であること,また全身状態が低下している場合や腹膜炎による腸管の炎症が著明である場合などでは二期的な手術が必要であることを述べた.

This is a report of small bowel perforation secondary to a metastasis from a primary adenocarcinoma of lung in a 62-year-old woman five months after resection of the primary tumor. She had received radiation therapy and corticosteroids after surgery. Features of this and five previously reported cases are discussed. Modern therapy may alter the course of pulmonary cancer resulting in more frequent observation of this rare complication.

Introduction: Abdominal trauma is defined as any injury to the abdomen and its containing viscera. Common penetrating injuries including gunshot or stab injuries are increasing worldwide. However, retroperitoneal gunshot injuries have a lower incidence than trans-abdominal trauma and can have substantially different outcomes. Case report: We report a series of three family members involved in gunshot violence over an18-month period. Each sustained retroperitoneal gunshot injuries with varying injuries patterns and treatment courses. Interestingly, one patient had a delayed small bowel perforation on day 6 post injury. Discussion: Retroperitoneal trauma following gun violence has a lower incidence than trans-abdominal trauma. There is a paucity of literature describing injury patterns following this type of injury and their subsequent management. In the context of penetrating retroperitoneal trauma, the retroperitoneal organs are at risk and therefore serial clinical and/or radiological assessment is necessary. Delayed small bowel injury as a consequence of retroperitoneal gunshot is an unusual finding, with no reports to our knowledge in the literature. Conclusion: this case series highlight that penetrating retroperitoneal trauma can produce a variety of injury patterns. Therefore a wide clinical acumen is needed to ensure a successful outcome. The trajectory of the bullet may help ascertain potential injuries, but serial assessment and observation are also important. Ultimately, individual cases must be treated accordingly, based on clinical stability, severity of injury and radiological findings. Despite initial stability, patients should always be observed for delayed complications. Keywords: Retroperitoneal, trauma, gunshot, management

This article reviews the various aetiologies of small bowel perforations and their management. In addition to the well-known aetiologies such as trauma, inflammation and circulatory disorders, several new causes of small bowel perforation have been described in recent years. The spectrum reaches from iatrogenic perforations during laparoscopic surgery or enteroscopies to drug-induced perforations with new anticancer agents. The management of small bowel perforations requires a concept consisting of the safe revision of the leaking bowel and the treatment of the peritonitis. Depending on the local situation and the condition of the patient, several treatment options are available. The surgical management of the bowel leak can range from a simple primary closure to a delayed restoration of bowel continuity. When the condition of the bowel or patient is frail, the risk of a failure of a closure or anastomosis is too high, and the exteriorization of the bowel defect as a primary measure is a safe option. The treatment of the peritonitis is also dependent on the condition of the patient and the local situation. Early stages of peritonitis can be treated by a simple peritoneal lavage, either performed by laparoscopy or laparotomy. Severe forms of peritonitis with multi-organ failure and an abdominal compartment syndrome need repeated peritoneal revisions. In such cases, the abdomen can only be closed temporarily. Different technical options are available in order to overcome the difficult care of these patients.

Since 1961, there have been a total of seven patients with small bowel perforation caused by metastatic lung carcinoma reported in the literature. Perforation of the small bowel to metastatic lung carcinoma must be considered when evaluating older patients who have histories of heavy cigarette smoking and signs and symptoms suggestive of pulmonary neoplasia. Primary resection and end-to-end anastomosis of the perforated bowel is the treatment of choice. No patient with small bowel perforation secondary to lung carcinoma has survived more than four months.

A patient with diffuse intestinal neurofbromatosis who presented with recurrent small bowel perforation is described. Such recurrent perforation has not been reported previously. Management at first perforation consisted of laparotomy, and excision of the perforated nodular lesion, with removal of the gall-bladder and appendix. The diagnosis of von Recktlinghausen's disease was confirmed by skin biopsy. Management of the second perforation was conservative, with administration of intravenous antibiotics, fluid replacement therapy, and nasogastric suction. The third perforation was treated surgically, with resection of the small bowel, leaving approximately 50 cm of small bowel. Such an approach represented a compromise between cure of the neurofibromatosis and leaving sufficient small bowel to allow satisfactory alimentation.

This report describes small-bowel perforation caused by giant-cell arteritis of the regional mesenteric vessels. No evidence of giant-cell arteritis at other sites was discovered and 18 months after presentation the patient remains well and symptom-free.

Introduction: Colonic perforations are known complications of percutaneous nephrolithotomy (PCNL). However, to the best of our knowledge, small bowel perforation has rarely been reported.Observation: We report the case of a 7-year-old girl who presented with a duodenal perforation in the early postoperative period after undergoing PCNL for a calculus sized 2.5 cm in the right renal pelvis. She was successfully managed conservatively. The diagnostic workup and management are discussed.Keywords: Calculus; Duodenum; Injury; Paediatric; Percutaneous nephrolithotomy

SUMMARY Two cases of small bowel perforation without free intraperitoneal gas are presented. The association of small bowel ileus with hollow viscus perforation is discussed.

Summary: A case of asymptomatic perforation of the small intestine by an intrauterine contraceptive device (a Dalkon shield) is presented. This is believed to be the first reported case of such an occurrence.

Ingested foreign bodies are often seen in clinical practice, but their radiographic demonstration is unusual unless they have a metallic or bony density. This report describes and illustrates a case of small bowel perforation secondary to an ingested wooden toothpick and emphasizes the role of CT in evaluating similar cases.

SummarySmall bowel perforation occurs in up to 2 percent of patients with abdominal tuberculous. Patients present with an acute abdomen. Resection of the diseased segment and 18 months treatment with anti-tuberculosis drugs is recommended.

Summary Primary nonspecific ulcer of the small intestine is seen infrequently. A group of cases has been reported recently with proposed pathogenetic effects of potassium chloride and thiazide. This paper presents a similar case with ulceration and perforation of the bowel probably caused by a partially digested enteric-coated potassium chloride tablet which was found in the ulcer bed.

The clinical notes and abdominal radiographs of 12 patients with proven typhoid perforation of the distal ileum have been reviewed. The radiographic findings on supine and erect plain abdominal films taken shortly before surgery or death are described. A large quantity of free intraperitoneal gas, an uncommon finding in small bowel perforation due to other causes, was present in half of the cases. Secondary changes typically seen with peritonitis were present in most cases although the distribution of bowel gas and distension was unusual.

✓ Two cases of small bowel perforation secondary to valve regulated ventriculoperitoneal shunts are reported. In both instances the shunts continued to function. There were no abnormal abdominal signs or symptoms. In one patient it is believed that recurrent gram-negative ventriculitis resulted from the distal small bowel perforation, and that this may be a clue to otherwise asymptomatic small bowel perforations.

Although accidental ingestion of foreign bodies is a common problem in the general population, most objects pass through the entire digestive tract without incidents (1). However, in 1% of cases, it causes complications such as acute abdomen due to intestinal perforation (2). In some cases, it can cause severe complications and even death; in the USA, 1,500 people die annually from foreign body ingestion (3).

Introduction Laparoscopy for abdominal surgical emergencies is gaining increasing acceptance given the spreading of advanced laparoscopic skills among modern surgeons, as it may allow at the same time an accurate diagnosis and appropriate treatment of acute abdomen. The use of the laparoscopic approach also in case of diffuse peritonitis is now becoming accepted provided hemodynamic stability, despite the common belief in the past decades that such severe condition represented an indication for conversion to open surgery or an immediate contraindication to continue laparoscopy. Crohn’s Disease (CD) is a rare cause of acute abdomen and peritonitis, only a few cases of CD acute perforations are reported in the published literature; these cases have always been approached and treated by open laparotomy. Case description We report on a case of a faecal peritonitis due to an acute perforation caused by a terminal ileitis in an undiagnosed CD. The patient underwent diagnostic laparoscopy followed by a laparoscopic ileo-colic resection and primary intracorporeal anastomosis, with a successful postoperative outcome. Conclusions Complicated CD has to be considered within the possible causes of small bowel non-traumatic perforation. Emergency laparoscopy with resection and primary intra-corporeal anastomosis can be feasible and may be a safe and effective minimally invasive alternative to open surgery even in case of faecal peritonitis, in selected stable patients and in presence of appropriate laparoscopic colorectal surgical skills and experience. To the best of our knowledge the present experience is the first ever reported case managed with a totally laparoscopic extended ileocecal resection with intracorporeal anastomosis in case of acutely perforated CD and diffuse peritonitis. Electronic supplementary material The online version of this article (doi:10.1186/s40064-015-1619-x) contains supplementary material, which is available to authorized users.

Intestinal metastasis of angiosarcoma is extremely rare. We herein report a case of intestinal perforation due to intestinal metastasis of angiosarcoma. The patient was a 72-year-old Japanese man with multiple recurrent angiosarcomas of the scalp. He developed acute abdominal pain with guarding, and we performed an emergency exploratory laparotomy. An intestinal perforation was found 80 cm from the ligament of Treitz, and partial jejunectomy was successfully performed. Macroscopic inspection revealed no obvious injury, ulcer, or tumor at or around the perforation site. Pathological examination revealed angiosarcoma cells penetrating through all layers of the jejunum at the site of intestinal perforation. This is the first reported case of intestinal perforation caused by indistinguishable intestinal metastasis of angiosarcoma. This case emphasizes intestinal metastasis of angiosarcoma as a possible cause of small bowel perforation in patients with advanced angiosarcoma, even when no visible tumor is present during surgery.

► Robotic surgery offers several advantages in the management of endometrial cancer. ► No long-term data exist regarding recurrence in patients undergoing robotic surgery. ► Metastasis or recurrence may result in bowel obstruction post surgery.

Excerpt Fabry's disease is a sex-linked disorder of glycolipid metabolism biochemically characterized by a deficiency or lack of the enzyme ceramide galactaryl hydralase (1). It is clinically manif...