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Background: Acute abdominal pain (AAP) constitutes 5–10% of all emergency department (ED) visits, with appendicitis being a prevalent AAP etiology often necessitating surgical intervention. The variability in AAP symptoms and causes, combined with the challenge of identifying appendicitis, complicate timely intervention. To estimate the risk of appendicitis, scoring systems such as the Alvarado score have been developed. However, diagnostic errors and delays remain common. Although various machine learning (ML) models have been proposed to enhance appendicitis detection, none have been seamlessly integrated into the ED workflows for AAP or are specifically designed to diagnose appendicitis as early as possible within the clinical decision-making process. To mimic daily clinical practice, this proof-of-concept study aims to develop ML models that support decision-making using comprehensive clinical data up to key decision points in the ED workflow to detect appendicitis in patients presenting with AAP. Methods: Data from the Dutch triage system at the ED, vital signs, complete medical history and physical examination findings and routine laboratory test results were retrospectively extracted from 350 AAP patients presenting to the ED of a Dutch teaching hospital from 2016 to 2023. Two eXtreme Gradient Boosting ML models were developed to differentiate cases with appendicitis from other AAP causes: one model used all data up to and including physical examination, and the other was extended with routine laboratory test results. The performance of both models was evaluated on a validation set (n = 68) and compared to the Alvarado scoring system as well as three ED physicians in a reader study. Results: The ML models achieved AUROCs of 0.919 without laboratory test results and 0.923 with the addition of laboratory test results. The Alvarado scoring system attained an AUROC of 0.824. ED physicians achieved AUROCs of 0.894, 0.826, and 0.791 without laboratory test results, increasing to AUROCs of 0.923, 0.892, and 0.859 with laboratory test results. Conclusions: Both ML models demonstrated comparable high accuracy in predicting appendicitis in patients with AAP, outperforming the Alvarado scoring system. The ML models matched or surpassed ED physician performance in detecting appendicitis, with the largest potential performance gain observed in absence of laboratory test results. Integration could assist ED physicians in early and accurate diagnosis of appendicitis. [ABSTRACT FROM AUTHOR]

Objectives: To determine the spectrum, clinical features and outcomes in systemic lupus erythematosus (SLE) patients with acute abdominal pain (AAP). Method: Medical records of SLE patients in a lupus cohort from January 1987 to June 2023 were reviewed. Patients with AAP requiring hospitalization were identified and categorized into 3 groups: lupus mesenteric vasculitis (LMV), non-LMV, and surgical AAP. Each AAP episode represented one patient. Results: Of 1,538 patients in the cohort, 62 (4.03%) had 93 episodes of AAP. After exclusion, 31 patients had 39 LMV episodes, and 30 had 40 non-LMV episodes (19 due to surgical AAP). Seventy-six of the 79 AAP episodes (96.20%) were in females, with a mean ± SD age and median (IQR) disease duration of 36.76 ± 13.60 years and 6 (2, 9) years, respectively. Patients in the LMV group had more fever, nausea and vomiting, and diarrhea than those in the non-LMV group. They also had more small bowel involvement, bowel wall thickening, target water enhancement signs, mesenteric vessels engorgement and mesenteric fat cloudiness, and higher SLE disease activity. These differences were more pronounced when compared to the surgical AAP group. Treatment with corticosteroids and immunosuppressive drugs gave favorable outcomes in the LMV group. Two of 40 (5.00%) non-LMV AAP patients died, of which 1 (5.26%) was in the surgical AAP group. Conclusion: LMV was common among SLE patients admitted for AAP. LMV usually presented with fever, gastrointestinal dysmotility symptoms, diffused abdominal pain, together with evidence of active disease. Localized abdominal pain with peritoneal signs favored surgical AAP. Key Points • Lupus mesenteric vasculitis is common among SLE patients presenting with acute abdominal pain. Its presence often associates with gastrointestinal symptoms together with other clinical manifestations of SLE • The signs in abdominal computed tomography findings are not specific and could be observed in other causes of abdominal pain in SLE. Interpretation of these signs should be cautionary and accompanied by history taking and physical abdominal findings • Treatment of lupus mesenteric vasculitis with corticosteroids alone, or in combination with immunosuppressive drugs, usually results in good outcomes [ABSTRACT FROM AUTHOR]

Background: The development of emergency department (ED) triage systems remains challenging in accurately differentiating patients with acute abdominal pain (AAP) who are critical and urgent for surgery due to subjectivity and limitations. We use machine learning models to predict emergency surgical abdominal pain patients in triage, and then compare their performance with conventional Logistic regression models. Methods: Using 38 214 patients presenting with acute abdominal pain at Zhongnan Hospital of Wuhan University between March 1, 2014, and March 1, 2022, we identified all adult patients (aged ≥18 years). We utilized routinely available triage data in electronic medical records as predictors, including structured data (eg, triage vital signs, gender, and age) and unstructured data (chief complaints and physical examinations in free-text format). The primary outcome measure was whether emergency surgery was performed. The dataset was randomly sampled, with 80% assigned to the training set and 20% to the test set. We developed 5 machine learning models: Light Gradient Boosting Machine (Light GBM), eXtreme Gradient Boosting (XGBoost), Deep Neural Network (DNN), and Random Forest (RF). Logistic regression (LR) served as the reference model. Model performance was calculated for each model, including the area under the receiver-work characteristic curve (AUC) and net benefit (decision curve), as well as the confusion matrix. Results: Of all the 38 214 acute abdominal pain patients, 4208 underwent emergency abdominal surgery while 34 006 received non-surgical treatment. In the surgery outcome prediction, all 4 machine learning models outperformed the reference model (eg, AUC, 0.899 [95%CI 0.891-0.903] in the Light GBM vs. 0.885 [95%CI 0.876-0.891] in the reference model), Similarly, most machine learning models exhibited significant improvements in net reclassification compared to the reference model (eg, NRIs of 0.0812[95%CI, 0.055-0.1105] in the XGBoost), with the exception of the RF model. Decision curve analysis shows that across the entire range of thresholds, the net benefits of the XGBoost and the Light GBM models were higher than the reference model. In particular, the Light GBM model performed well in predicting the need for emergency abdominal surgery with higher sensitivity, specificity, and accuracy. Conclusions: Machine learning models have demonstrated superior performance in predicting emergency abdominal pain surgery compared to traditional models. Modern machine learning improves clinical triage decisions and ensures that critically needy patients receive priority for emergency resources and timely, effective treatment. [ABSTRACT FROM AUTHOR]

Internal hernias, including Left para duodenal Hernias (LPDH), are rare and challenging to diagnose due to their nonspecific symptoms and complex anatomical presentation. This report presents a unique case of a 29-year-old female with preoperatively diagnosed uncomplicated LPDH, complicated by distal bowel ischemia—a manifestation not extensively documented in existing literature. Initial imaging revealed dilated jejunal loops indicative of LPDH, with subsequent contrast-enhanced computed tomography (CECT) showing ischemic changes in bowel segments distal to the hernia. Surgical exploration confirmed 120 cm of gangrenous bowel, necessitating resection and jejunostomy. This case highlights the diagnostic and therapeutic challenges of LPDH and highlights the crucial role of advanced imaging in identifying associated complications.

Introduction: Mesenteric volvulus is a rare cause of abdominal pain and bowel obstruction in elderly patients. When a mesenteric volvulus occurs in adult patients, the symptoms are often non-specific, which contributes to delays in diagnosis.Case Report: We present a case of a 75-year-old female who presented with non-specific abdominal pain. The rare whirlpool sign on computed tomography identified a mesenteric volvulus as the cause of small bowel obstruction. She was taken to the operating room and, after successful resection of the small bowel, she recovered and ultimately was discharged home.Conclusion: Early identification of a whirlpool sign and early surgical consultation are key to providing the best chance for salvage of ischemic small bowel due to mesenteric volvulus and to prevent a fatal outcome.

Abstract Background Acute diverticulitis is commonly misdiagnosed among patients with acute abdominal pain in the emergency department (ED). There are predictive scores that assist in the diagnosis of acute left-sided diverticulitis, but no scoring system is available for diagnosing acute diverticulitis without regard to the affected side. Therefore, developing a predictive score for diagnosing acute diverticulitis that is not limited to the left side will guide physicians in making a diagnosis and increase the appropriateness of computed tomography. This study aimed to establish a predictive score for diagnosing acute diverticulitis. Method This single-centre retrospective study included adult patients (≥ 18 years) who presented to the ED with acute abdominal pain. Multivariate logistic regression analysis was used to identify essential factors for diagnosing acute diverticulitis, and the Akaike information criterion was calculated to identify significant predictive factors for diagnosing acute diverticulitis using a clinical scoring system. Results Of 424 patients who fulfilled the inclusion criteria, 72 (17%) were diagnosed with acute diverticulitis. The significant factors associated with acute diverticulitis were age ≥ 60 years (adjusted odds ratio (adj.OR) 2.23, 95% confidence interval (CI): 1.20 − 4.14, p = 0.01), duration of abdominal pain ≥ 48 h (adj.OR 2.64, 95% CI: 1.28 − 5.45, p = 0.017), history of a diverticulum (adj.OR 7.77, 95% CI: 3.27 − 18.45, p

Background: Acute diverticulitis is commonly misdiagnosed among patients with acute abdominal pain in the emergency department (ED). There are predictive scores that assist in the diagnosis of acute left-sided diverticulitis, but no scoring system is available for diagnosing acute diverticulitis without regard to the affected side. Therefore, developing a predictive score for diagnosing acute diverticulitis that is not limited to the left side will guide physicians in making a diagnosis and increase the appropriateness of computed tomography. This study aimed to establish a predictive score for diagnosing acute diverticulitis. Method: This single-centre retrospective study included adult patients (≥ 18 years) who presented to the ED with acute abdominal pain. Multivariate logistic regression analysis was used to identify essential factors for diagnosing acute diverticulitis, and the Akaike information criterion was calculated to identify significant predictive factors for diagnosing acute diverticulitis using a clinical scoring system. Results: Of 424 patients who fulfilled the inclusion criteria, 72 (17%) were diagnosed with acute diverticulitis. The significant factors associated with acute diverticulitis were age ≥ 60 years (adjusted odds ratio (adj.OR) 2.23, 95% confidence interval (CI): 1.20 − 4.14, p = 0.01), duration of abdominal pain ≥ 48 h (adj.OR 2.64, 95% CI: 1.28 − 5.45, p = 0.017), history of a diverticulum (adj.OR 7.77, 95% CI: 3.27 − 18.45, p < 0.001), absence of nausea and vomiting (adj.OR 3.42, 95% CI: 1.65 − 7.10, p < 0.001), absence of anorexia (adj.OR 3.33, 95% CI: 1.34 − 8.33, p = 0.026), absence of tachycardia (adj.OR 3.51, 95% CI: 1.39 − 8.87, p = 0.003), and abdominal guarding (adj.OR 2.99, 95% CI: 1.52 − 5.91, p = 0.002). These predictive factors were converted into predictive scores for diagnosing acute diverticulitis. For the score of ≥ 4, the sensitivity and specificity were 73.24% (95% CI: 0.61–0.83) and 80.40% (95% CI: 0.76–0.84), respectively, and the negative predictive value was 93.71% (95% CI: 0.90–0.96). No significant signs, symptoms, or laboratory findings were associated with complicated diverticulitis. Conclusion: Predictive factors for diagnosing acute diverticulitis included age ≥ 60 years, duration of abdominal pain ≥ 48 h, history of a diverticulum, abdominal guarding, and absence of nausea and vomiting, anorexia, and tachycardia. A predictive score ≥ 4 suggested the presence of acute diverticulitis. [ABSTRACT FROM AUTHOR]

Introduction: Epiploic appendagitis (EA) is an essential cause of abdominal pain that can be confused with more typical causes such as acute diverticulitis and appendicitis. Epiploic appendagitis accounts for 1% of all cases of abdominal pain in adults. The scarcity of information has limited its recognition as an essential nonsurgical cause of acute abdominal pain. Methods:We performed a systematic review of all EA cases published.We searched Scopus, Medline,Web of Science, and Google Scholar to retrieve all available studies from January 2000 to November 2023. Results: 196 case reports and case series were analyzed, with 371 patients with EA included. The mean age at the time of diagnosis was 39 years. Most patients were male (59%). The primary presenting symptoms were pain (100%), tenderness (59.5%), and rebound tenderness (27.4%). The left abdomen was the most common localization of pain (53%). The most frequently identified differential diagnoses were acute appendicitis (26.4%) and acute diverticulitis (16.1%). Most patients (53%) were treated conservatively, and 98 (26.4%) underwent surgical treatment. A significant difference in the choice of treatment was found for signs and symptoms such as rebound tenderness, nausea, anorexia, and diarrhea. Conclusions: Acute EA is an essential clinical condition of rare occurrence that might present a diagnostic challenge, as it can masquerade as another acute abdominal pain etiology. The optimal management of EA is conservative, so a higher recognition by surgeons and emergency physicians is essential to avoid unnecessary surgical interventions and their associated consequences. [ABSTRACT FROM AUTHOR]

Neuroendocrine tumors (NETs) are notably rare and frequently arise from the gastrointestinal tract. Generally asymptomatic, NETs uncommonly result in acute abdominal pain. We present a case of known metastatic NET manifesting as acute-on-chronic mesenteric ischemia due to the involvement of the superior mesenteric artery (SMA) and vein (SMV). A 63-year-old female with metastatic NET presented with acute-onset abdominal pain. The patient was hemodynamically stable but uncomfortable appearing with significant pain. Imaging demonstrated decreased enhancement of several small bowel loops within the right lower quadrant concerning for bowel ischemia with a mesenteric mass encasing the SMA and SMV. Surgical intervention revealed a nonviable loop of small bowel. Second-look laparotomy was performed with viable remaining bowel, and an ileocolic anastomosis was successfully created. Acute-onset abdominal pain in a patient with NET warrants urgent. Mesenteric ischemia, while rare, should not be overlooked, as timely diagnosis and intervention are imperative. [ABSTRACT FROM AUTHOR]

In children, 90% cases of intussusception are idiopathic and the remaining 10% are attributed to underlying diseases (most commonly due to Meckel's diverticulum, polyps then either duplication cyst or mesentery cysts, and rarely due to Burkitt's lymphoma). The occurrence of acute intestinal intussusception caused by Burkitt's lymphoma in children under the age of 5 is exceedingly rare. Burkitt's lymphoma presents with diverse clinical manifestations, often leading to the identification of an abdominal tumor in pediatric patients. This highly aggressive and rapidly proliferating neoplasm can induce indirect symptoms due to compression or direct involvement of the intestinal lumen, resulting in intussusception. Herein, we present a case report of ileocolic-type intussusception in a 2-year-old boy, which was attributed to the coexistence of Burkitt's lymphoma and Meckel's diverticulum. Notably, this patient exhibited atypical clinical features for Burkitt's lymphoma and did not belong to the high-risk demographic associated with this rare disease. Furthermore, this case represents a unique combination involving the most prevalent cause of Meckel's diverticula and the rarest etiology of Burkitt's lymphoma.

BackgroundAcute abdominal pain in pediatrics is a medical emergency that requires special attention. During COVID-19 pandemic, this disease presented in pediatric age by different presentations including abdominal presentations.The affected children are presented with abdominal pain, which may be caused by surgical causes or by the virus itself that necessitate surgical consultation.PurposeThis study highlights the impact of the coronavirus pandemic on pediatric patients with acute abdominal pain regarding the presentation, clinical evaluation, and surgical management.MethodsA retrospective cohort study was done through the collection of data from medical records and authors’ data repositories of pediatric patients presented with acute abdomen from March 2020 to March 2022, in three pediatric surgery tertiary centers.ResultsEighty-four pediatric patients with acute abdominal pain were included in this study. The diagnosis of acute appendicitis was found in 31 patients (36.9%). Generalized abdominal pain was noted in 17 patients (20.2%) and presentation mimicked acute cholecystitis was occured in 14 patients (16.7%). ultrasonography revealed intussusception in 12 cases (14.3%). Multisystem inflammatory syndrome in children (MIS-C) was present in 9 cases (10.7%) and only one case of pancreatitis (1.2%). Conservative management was successful in 66 cases (78.6%), while operative intervention was needed in18 cases (21.4%).ConclusionDuring the COVID-19 pandemic, acute abdominal pain in children was frequently observed. Careful follow up is critically important as most cases do not necessitate surgical intervention. It is crucial to consider COVID-19 as a differential diagnosis in children presenting with acute abdominal pain, particularly in cases of atypical appendicitis and intussusception to prevent unnecessary surgical procedures.

A rectus sheath haematoma (RSH) is a relatively rare cause of acute abdominal pain that is becoming more prevalent due to an increase in anticoagulant therapy. Of its associated complications, acute obstructive uropathy is exceedingly rare. This is a case of a 62-year-old lady who presented with abdominal pain caused by an RSH which then led to obstructive uropathy. She had undergone laparoscopic removal of a gastric band 6 days prior and due to a mechanical mitral valve, required ongoing anticoagulation. Initially, she had a contained RSH, but this subsequently decompressed into the extraperitoneal space, causing acute obstructive uropathy secondary to external compression. She was managed with ureteric stenting and her anticoagulation was appropriately modified throughout her admission. This case highlights that the challenging aspect of RSH management involves tailoring treatment to address individual patient factors and the location of the haematoma itself. [ABSTRACT FROM AUTHOR]

Necrotizing pancreatitis (NP) is a severe form of acute pancreatitis associated with high morbidity and mortality. The management of infected necrotizing pancreatitis (INP) has evolved from open surgical necrectomy to minimally invasive techniques, such as percutaneous catheter drainage (PCD). We report the case of a 71-year-old male with a history of cholelithiasis who presented with acute abdominal pain, nausea, and vomiting. Initial imaging revealed an enlarged pancreas with peripancreatic fluid collections. Conservative treatment improved his condition, but nine days later signs of sepsis, including a persistent fever were presented. Computed tomography (CT) verified several large gas-containing fluid collections spreading from the pancreas to the left iliac crest along with bilateral pleural effusions. The patient underwent PCD with multiple drains inserted. Microbiological analysis showed Meropenem-resistant E. coli , leading to a change in antibiotic therapy. Follow-up imaging confirmed the resolution of fluid collections, and the patient recovered without requiring laparotomy. PCD has emerged as a crucial component of the step-up approach in managing INP. Compared with open necrectomy, PCD offers lower mortality and morbidity rates. The PAncreatitis, Necrosectomy versus sTEp up appRoach (PANTER) trial and subsequent studies have validated the efficacy of PCD, demonstrating its ability to reduce complications and healthcare costs while improving patient outcomes. PCD is a safe and effective treatment for INP, representing a valuable alternative to traditional surgical methods. This case underscores the importance of minimally invasive strategies in the management of NP. [ABSTRACT FROM AUTHOR]

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Abstract Background The aim of the study is to investigate the proportion and clinical features of previous spontaneously ruptured ovarian endometrioma among women who underwent elective surgery for endometrioma. Methods This retrospective study was based on a cohort of elective surgeries for endometrioma performed by the same gynecologic team at Peking Union Medical College Hospital from January 2017 to October 2022. Patients diagnosed with previous spontaneously ruptured endometrioma during elective surgery were enrolled in the ruptured group. In the same cohort, patients with unruptured endometrioma treated during the same period were selected as the unruptured group by 1:2 matching according to age. Demographic and clinical information were collected and compared between two groups. Results A total of 422 patients in the cohort were diagnosed with endometrioma. There were 38 patients (9.0%) in ruptured group and 76 patients in unruptured group. All enrolled participants were treated by laparoscopic surgery. In ruptured group, 86.8% patients had a history of acute abdominal pain, which was only 13.2% in unruptured group (P

Ileosigmoidal knotting (ISK) is a rare, possibly fatal cause of intestinal obstruction. ISK is a compound volvulus that is more common in Africa and Asia. ISK is mostly seen in adults, pediatric cases reported in the literature are much rarer. In this report, we present the first reported case of ISK in a pediatric patient from Nepal. An 8-year-old male child presented with symptoms of abdominal pain, vomiting, and obstipation. The abdomen was distended with generalized tenderness. Erect abdominal X-ray showed multiple air-fluid levels. Intraoperatively, gangrenous ileum loops were entangled around the sigmoid, and resection of the gangrenous ileum and sigmoid was performed. An end-to-end colo-colic anastomosis from the descending colon to the remaining sigmoid with a double-loop ileostomy was performed. Pediatric ISK is a rare fatal form of intestinal obstruction that progresses quickly to gangrene. Clinical signs and symptoms are nonspecific, making preoperative diagnosis challenging. [ABSTRACT FROM AUTHOR]

Adenocarcinoma and lymphoma, potential complications of Crohn's disease (CD), may result in small intestinal perforations, particularly in those on immunosuppressive therapy. The ileum is typically the site of small intestinal perforations in CD, and the link between CD and lymphoma remains uncertain. This case report explores a long-term CD patient on immunosuppressive therapy who presented with acute abdominal pain. Imaging revealed signs of intestinal perforation, successfully managed with surgery. The final pathology report confirms the diagnosis of diffuse large B-cell lymphoma. This report sheds light on the complicated nature of gastrointestinal lymphoma in CD patients. [ABSTRACT FROM AUTHOR]

Background: The aim of the study is to investigate the proportion and clinical features of previous spontaneously ruptured ovarian endometrioma among women who underwent elective surgery for endometrioma. Methods: This retrospective study was based on a cohort of elective surgeries for endometrioma performed by the same gynecologic team at Peking Union Medical College Hospital from January 2017 to October 2022. Patients diagnosed with previous spontaneously ruptured endometrioma during elective surgery were enrolled in the ruptured group. In the same cohort, patients with unruptured endometrioma treated during the same period were selected as the unruptured group by 1:2 matching according to age. Demographic and clinical information were collected and compared between two groups. Results: A total of 422 patients in the cohort were diagnosed with endometrioma. There were 38 patients (9.0%) in ruptured group and 76 patients in unruptured group. All enrolled participants were treated by laparoscopic surgery. In ruptured group, 86.8% patients had a history of acute abdominal pain, which was only 13.2% in unruptured group (P < 0.001). Compared to unruptured group, patients diagnosed with ruptured endometrioma had a lower BMI (P = 0.021), larger maximum diameter of endometrioma (P = 0.040), higher proportion of cul-de-sac partial obliteration rather than complete obliteration (P = 0.003). Conclusions: Spontaneous rupture of endometrioma is not rare. The proportion of spontaneous rupture of endometrioma in our study was higher than that reported in the literatures. In women with endometrioma, the onset of acute abdominal pain should be considered a rupture of cyst, especially in patients with big cysts. [ABSTRACT FROM AUTHOR]

Aim: To develop and test a questionnaire using the Fundamentals of Care framework to measure person‐centred pain management. Design: Cross‐sectional exploratory descriptive design. Methods: Development in three phases: (a) literature search for questionnaires measuring person‐centred pain management, (b) seven‐step process developing items using thematic analysis, (c) initial feasibility and validity testing. Theoretical and empirical evidence was used, including the 'Strategic and Clinical Quality Indicators in Postoperative Pain management' questionnaire, the Fundamentals of Care framework and person‐centredness principles. Theoretical experts (n = 2) reviewed the questionnaire, further evaluated by providers (n = 5) and patients (n = 5) using a think‐aloud process, and by additional questions in the questionnaire answered by n = 100 patients. The questionnaire was tested February to March 2021, at four surgical wards in a university hospital. Results: The evaluation showed initial support for feasibility and validity, and the questionnaire was found to represent and be sensitive to capture the patients' experiences of person‐centred pain management and being easy to answer. The 100 patients with acute abdominal pain who answered the questionnaire (aged 18–89 years, 46 women and 54 men), identified missing elements of fundamental care in their pain management, indicating that the questionnaire is sensitive to capture specific areas for improvement. Conclusion: This first attempt at transforming the essential components of person‐centred pain management into measurable items in a questionnaire was found promising. The questionnaire is suggested to be further tested for psychometric properties and patient benefit to provide clinical guidance in acute surgical care to meet the patient care need of pain management. Implications for the profession and/or patient care: The developed questionnaire addresses the need of nurses and nursing leaders to evaluate the delivery of person‐centred pain management in acute surgical care, to relieve the patient from pain. Patient or public contribution: Patients and providers were involved in testing the questionnaire. [ABSTRACT FROM AUTHOR]

Key Clinical Message: We report a case of arterial and venous thrombosis during induction therapy. This case emphasizes considering some degree of caution for thrombotic events in APL patients which was represented in our case as abdominal pain. Rapid initiation of anticoagulation and preventive measures is suggested for better management of the condition. [ABSTRACT FROM AUTHOR]

Abstract Although endometriosis is a common gynecological condition in women of reproductive age, a complication of endometriosis is rarely considered as the differential diagnosis of acute abdominal pain in that context. However, acute events in women with endometriosis can represent life-threatening conditions, which require emergent treatment and often surgical management. Mass effect of endometriotic implants can give rise to obstructive complications, specifically occurring in the bowel or in the urinary tract, while inflammatory mediators released by ectopic endometrial tissue can lead to inflammation of the surrounding tissues or to superinfection of the endometriotic implants. Magnetic resonance imaging is the best imaging modality to reach the diagnosis of endometriosis, but an accurate diagnosis is possible on computed tomography, especially in the presence of stellar, mildly enhanced, infiltrative lesions in suggestive areas. The aim of this pictorial review is to provide an image-based overview of key findings for the diagnosis of acute abdominal complications of endometriosis. Graphical Abstract

Abstract Background A urachal cyst has a rare incidence that has been reported as 1/5,000 live birth. Case presentation We report two patients with a complicated urachal cyst, a 5-year-old female who presented to the emergency department with severe abdominal pain and a 3-year-old female presenting with abdominal pain and constipation. Upon laparoscopic exploration both patients had complicated urachal cysts which were adherent to the urinary bladder. Conclusion Complicated urachal cysts can present with acute abdominal pain.

Background: Accessory spleen (AS) is a rare condition that usually does not cause any symptoms. However recurrent torsion and detorsion of AS commonly happen in the case of AS with long pedicles. Thus diagnostic and treatment procedure is needed to prevent further complication in this case. Case presentation: An extreme case of an Austronesian 22-year-old college student who presented clinical symptoms of crampy abdominal pain in the left upper quadrant (LUQ) three days before being administered in a hospital. The pain was periodically worsened and relieved for the past year due to recurrent torsion and detorsion of the accessory spleen. Radiologic findings were accessory spleen located in the lienorenalis region with the size of 1.6 x 1.8 x 1.4 cm and the vascular accessory spleen extends from the splenic pedicle to the left splenorenal region. The intraoperative finding was a blackish-brown mass with spongy consistency with 0.5 cm of the pedicle. Conclusion: A combination of USG and CT scan with arterial and venous phase is preferred to diagnose the accessory spleen early. While the findings of the accessory spleen with long pedicle are highly suggested to be treated using modified anti-Trendelenburg 3-port laparoscopic excision of the accessory spleen (LEAS).

Acute abdominal pain in pregnant women may complicate the diagnostic process of acute abdominal pain because of anatomical and physiological changes and limitations of computed tomography examinations related to radiation exposure. Here, we present the case of a 35-year-old female in her 10th week of pregnancy who was seen in the emergency department with unilateral abdominal pain and gross hematuria. Ultrasound detected only hydronephrosis and failed to identify ureteral stones, but magnetic resonance imaging revealed a diagnosis of idiopathic renal hemorrhage and intraductal ureteral hematoma, not ureteral stones. Although magnetic resonance imaging for pregnant women has the disadvantages of prolonged scan time and difficulty in image interpretation, no harm or complications to the mother or fetus have been reported. Magnetic resonance imaging may be considered in assessing acute abdominal pain in pregnant women, especially when the diagnosis is uncertain, based on shared decision-making with the patient and assessing the clinical situation and availability.

Abstract Background Unfavorable outcomes occur in patients with acute abdominal pain who visit the emergency department (ED). We aimed to determine the factors associated with unfavorable outcomes in patients with acute abdominal pain visiting the ED. Methods This retrospective cohort study was conducted from July 1, 2015 to June 30, 2016. The inclusion criterion was patients aged older than 18 years who presented to the ED with acute abdominal pain. Significant factors associated with unfavorable outcomes were examined using univariate and multivariate logistic regression analyses. Results A total of 951 patients were included in the study. Multivariate logistic regression analysis showed that the ED length of stay (EDLOS) > 4 h (adjusted odds ratio (AOR) 2.62, 95% confidence interval [CI]: 1.33–5.14; p = 0.005), diastolic blood pressure (DBP) 75% (AOR 2.83, 95% CI: 1.39–5.75; p = 0.004) were revealed as significant factors associated with unfavorable outcomes. Conclusions The present study revealed that the significant clinical signs associated with the occurrence of unfavorable outcomes were DBP 75%. Additionally, patients with abdominal pain visiting the ED who had an EDLOS longer than 4 h were associated with unfavorable outcomes.

Abstract Background Acute abdomen is a series of acute and severe abdominal diseases commonly encountered in clinic. It is important to strengthen the image teaching of acute abdomen for undergraduates. Aim This study aimed to explore the application effect of SPARK[sub-speciality (S), problem-based learning (P), assessment (A), report (R) and reading skill (K)] teaching mode in the experimental teaching of acute abdomen for undergraduate medical students. Methods We selected a total of 58 third year medical students for observation. The students were divided into experimental group and control group. Among them, 29 students in the experimental group studied in SPARK teaching mode, 29 students in the control group studied in traditional teaching mode. The two groups of students were tested after the theory class, before and after the experimental class, and one week after the experimental class, to compare the application effects of the two teaching modes. After the test one week after the experimental class, the two groups of students jointly adopted SPARK mode to learn, and were tested again one month after the experimental class to compare whether the two groups of students achieved the same results. The total score of all tests was 150. Results The average scores of the experimental group and the control group after theory class were (69.0 ± 26.4) and (72.1 ± 24.1) respectively, with no statistical difference (t = 0.468, P = 0.642). The average scores of the experimental group before, after and one week after the experimental class were higher than those of the control group. The experimental group was (84.5 ± 23.1), (109.7 ± 23.8), (105.5 ± 31.0) respectively, and the control group was (52.8 ± 15.1), (93.8 ± 17.0), (80.0 ± 22.8) respectively. The differences were statistically significant (t = -6.195, P = 0.00; t = -2.919, P = 0.05; t = -3.569, P = 0.01). The average scores of the experimental group and the control group after one month were (99.0 ± 31.0) and (95.5 ± 25.6) respectively, and there was no significant difference between the two groups (t = -0.462, P = 0.646). Conclusions The SPARK teaching mode was helpful for undergraduate medical students to consolidate image foundation, improve image reading skills.

Background: Uterine perforation is a rare condition that occurs spontaneously and with less prevalence in intestinal diseases, including malignancies. Case Presentation: A 61-year-old woman with a history of the rectal tumor was referred due to acute abdominal pain, and pyometra was detected caused by uterine-colon fistula. During surgery, uterine perforation was observed, and the patient was treated with antibiotics and drainage. The pathology examination confirmed the invasion of colon cancer into the uterus. Conclusion: Although uterine perforation caused by pyometra and uterine-colon fistula is a rare occurrence, in any patient with colorectal malignancy who presents with an acute abdomen, it should be considered one of the complications of cancer, and antibiotic treatment should be started on time

Introduction: Porphyrias are metabolic disorders caused by enzymatic alterations in the biosynthesis of the heme group of heme proteins. The clinical spectrum of porphyrias is associated with the location of the damage in the heme formation chain, which can range from neurovisceral manifestations to cutaneous alterations related to photosensitivity. The diagnosis of this pathology can be difficult since it is a rare disease and the symptoms are nonspecific. Objectives: The present study reports the diagnosis steps and clinical suspicion of a case of acute intermittent porphyria. Case Report: A 23-years-old male patient initially presented with nonspecific abdominal pain to the Emergency Room of Hospital João XXIII (Belo Horizonte/MG). The diagnostic investigation became more directed because of the positive family history for porphyria; until this information was provided, approaching the case was challenging. Diagnostic accuracy is essential considering the risk of using medications commonly used in the Emergency Room and which are aggravating for porphyria. The case was managed with symptom support and caloric intake until the medication (hematina) was acquired through judicialization. Conclusion: Acute hepatic porphyrias are a group of rare diseases with severe and nonspecific manifestations. However, patients with unexplained abdominal pain, mainly associated with neuropsychiatric symptoms and positive family history, should be screened for urinary porphyrins because recognizing the disease is essential, and hematin therapy should be promptly introduced.

Acute endometritis belongs to the spectrum of inflammatory diseases of the upper genital system, characterized as pelvic inflammatory disease (PID) and is an ascending inflammation located in the endometrial cavity. It is a cause of acute abdominal pain and requires early clinical diagnosis and treatment. The present study is a presentation of a case with acute endometritis who was hospitalized at the Obstetrics and Gynecology Department of Larissa General Hospital. [ABSTRACT FROM AUTHOR]

A congenital diaphragmatic hernia occurs when the diaphragm has a structural defect that allows the migration of abdominal organs into the chest cavity. It is called late presentation when its diagnosis does after 30 days of life. More than 60% of patients with congenital diaphragmatic hernia are misdiagnosed. The most common misdiagnoses are pleural effusion, pneumonia, pneumothorax, pneumatocele, and lung abscess. We present a case of a 3-year-old female who attended the emergency room due to abdominal pain, nausea, vomiting, intolerance to the oral route, and respiratory distress. The chest X-ray showed migration of the gastric chamber towards the thorax, displacement of the cardiac silhouette and the mediastinal structures to the right, and the tip of the nasogastric tube located in the left hemithorax. The doctors concluded a late presentation diaphragmatic hernia. The patient received surgical treatment, which was successful. This paper highlights the importance of suspecting the diagnosis of late-onset congenital diaphragmatic hernia when treating pediatric patients with respiratory distress without another apparent cause, abdominal pain, nausea, and vomiting. [ABSTRACT FROM AUTHOR]

This study reports a rare case of primary extragenital choriocarcinoma in the spleen presenting as acute abdominal pain. We expect this case to provide more valuable information for clinicians in the future. The patient was a 22-year-old woman, with a healthy child and a history of bilateral ovarian cyst resection a week before, who presented with severe and sudden pain in the left upper abdomen. The patient was admitted to the emergency department. Emergency ultrasound revealed a huge solid mass in the enlarged spleen. Emergency computed tomography examination suggested acute splenic rupture. Microscopic examination confirmed that the mass contained nested syncytiotrophoblast and cytotrophoblast cells, and the serum beta-human chorionic gonadotropin (β-hCG) level was 54,547.6 IU/L (normal β-hCG level <5 IU/L) after surgery. Primary extragenital choriocarcinoma in the spleen was considered as the cause of splenic rupture. Primary extragenital choriocarcinoma of the spleen is extremely rare. Serum β-hCG tests and systemic abdominal ultrasonography are of great value for the diagnosis of the disease. [ABSTRACT FROM AUTHOR]

Undifferentiated abdominal pain in adults is a common chief complaint in acute care clinics and emergency departments worldwide, representing up to 10% of visits to emergency departments. Many patients have a non-specific presentation and an initial workup with labwork, urine analysis or X-ray might not reveal a specific diagnosis. Although bowel intussusception is a primarily pediatric disease, adult intussusception is a recognized but rare cause of bowel obstruction often requiring surgical intervention. However, recent data from advanced multi-detector computed tomography imaging shows that milder or recurring cases in adults have been underrecognized. Multi-detector computed tomography is still the imaging gold standard for detecting intussusception in adults, but new data showed that sonographers with basic training using the point-of-care ultrasound approach have a reasonable accuracy in detecting this pathology. As the point-of-care ultrasound for undifferentiated abdominal pain is an emerging core skill in the acute care setting, knowledge of sonographic signs of intestinal intussusception should be included in the skill set of physicians. Sonographic findings in adults mimic pediatric cases, but different location patterns and higher malignancy rates exist in adults. In this manuscript, we will review the current literature on adult intussusception and summarize key knowledge of intestinal intussusception in adults. We will present four adult patients diagnosed with different types of adult acute bowel intussusception using the point-of-care ultrasound and describe a focused scanning approach with typical sonographic findings. [ABSTRACT FROM AUTHOR]

Background: Abdominal pain is one of the most frequent causes for emergency department (ED) visits. The quality of care and outcomes are determined by time-dependent interventions with barriers to implementation at crowded EDs. Objectives: The study aimed to analyze three prominent quality indicators (QI) including pain assessment (QI1), analgesia in patients reporting severe pain (QI2), and ED length of stay (LOS) (QI3) in adult patients requiring immediate or urgent care due to acute abdominal pain. We aimed to characterize current practice regarding pain management, and we hypothesized that extended ED LOS (≥ 360 min) is associated with poor outcomes in this cohort of ED referrals. Methods: This is a retrospective cohort study enrolling all patients with acute abdominal pain as the main cause of ED presentation, triage category red, orange, or yellow, and age ≥ 30 years during two months period. Univariate and multivariable analyses were deployed to determine independent risk factors for QIs performance. For QI1 and QI2, compliance with the QIs were analyzed, while 30-day mortality was set as primary outcome for QI3. Results: Overall, 965 patients were analyzed including 501 (52%) males with a mean age of 61.8 years. Seventeen percent (167/965) of the patients had immediate or very urgent triage category. Age ≥ 65 years, and red and orange triage categories were risk factors for non-compliance with pain assessment. Seventy four per cent of patients with severe pain (numeric rating scale ≥ 7) received analgesia during the ED visit, in median within 64 min (IQR 35–105 min). Age ≥ 65 years and need for surgical consultation were risk factors for prolonged ED stay. After adjustment to age, gender and triage category, ED LOS ≥ 360 min proved to be independent risk factor for 30-day mortality (HR 1.89, 95% CI 1.71–3.40, p = 0.034). Conclusion: Our investigation identified that non-compliance with pain assessment, analgesia and ED length of stay among patients presenting with abdominal pain to ED results in poor quality of care and detrimental outcomes. Our data support enhanced quality-assessment initiatives for this subset of ED patients. [ABSTRACT FROM AUTHOR]

Background: In order to reduce radiation exposure, the goal of this study was to examine the roles of computed tomography and ultrasound in the evaluation of acute abdomen. It also sought to determine whether ultrasound alone would be sufficient in most cases. Method: For non-traumatic acute abdominal discomfort that lasted less than three days, 50 adult patients visited the emergency room. This prospective observational study was authorized by the institutional review board. The surgery department of Sharan Nursing Home, Motihari, Bihar performed the radiological evaluation of the abdomen using ultrasonography and CT scans (both non-contrast and contrast-enhanced). Trauma and being pregnant were the exclusion factors. Results: There was no statistically significant difference between the overall sensitivity of the ultrasound and the CT (p = 0.018). Additionally, there were no appreciable differences between the sensitivity of ultrasound and CT in diagnosing frequent causes of acute abdomen, such as acute cholecystitis, acute appendicitis, intestinal obstruction, pancreatitis, and ureteric calculi. Only patients with retro-caecal appendicitis, cases of intestinal blockage where the transition point needed to be defined, and patients with pancreatitis where the CT Severity index needed to be obtained were candidates for CT. Conclusion: Considering that ultrasound has been shown to have a sensitivity that is comparable to CT in the majority of clinical scenarios, we conclude that ultrasound should continue to be the primary imaging modality in all patients with acute abdomen in order to prevent radiation exposure. It is also a more economical inquiry. As a result, CT should only be used in a small number of clinical circumstances where ultrasound is severely inconclusive. Recommendation: Both CT and ultrasonography tests must be conducted in order to ensure a certain conclusion in acute abdomen cases.

Jejunoileal bypass (JIB) was an early bariatric procedure that involved bypassing most of the small bowel resulting in malabsorption and weight loss. Due to serious complications associated with the procedure, JIB was largely discontinued by the mid-1980s. We report the case of a 77-year-old woman with a history of JIB 31 years earlier. In 2022, she was hospitalized for acute abdominal pain. A computed tomography (CT) scan revealed a suspicion of internal hernia (IH) with a typical swirl sign. Due to the quick relief of symptoms an emergency surgery was not considered at the time. Nevertheless, a subsequent operation revealed a large mesenteric defect, adhesions and 100 cm of effective small bowel left. Although the procedure is no longer performed, some patients with JIB are still alive and develop late complications. To our knowledge, this is the first case report describing an IH in a patient who has undergone JIB. [ABSTRACT FROM AUTHOR]

Knowledge of variations in arterial vascular supply is crucial in HPB and general surgery. Although the arterial configuration of the coeliac trunk and the superior mesenteric artery had been investigated, there are still arterial branching patterns to be described. We herein present the case of an 84-year-old male patient who underwent total pancreatectomy due to a not specified pancreas head tumor with a replacing right hepatic artery according to Michel's classification III and a replacing middle colic artery arising from the splenic artery and running on the ventral side of the pancreas. To the best of our knowledge, this arterial branching pattern has never been described so far. In this case, two arterial variations had been presented with a type III arterial supply according to Michel's classification, and a replacing middle colic artery arising from the SA. [ABSTRACT FROM AUTHOR]

Although endometriosis is a common gynecological condition in women of reproductive age, a complication of endometriosis is rarely considered as the differential diagnosis of acute abdominal pain in that context. However, acute events in women with endometriosis can represent life-threatening conditions, which require emergent treatment and often surgical management. Mass effect of endometriotic implants can give rise to obstructive complications, specifically occurring in the bowel or in the urinary tract, while inflammatory mediators released by ectopic endometrial tissue can lead to inflammation of the surrounding tissues or to superinfection of the endometriotic implants. Magnetic resonance imaging is the best imaging modality to reach the diagnosis of endometriosis, but an accurate diagnosis is possible on computed tomography, especially in the presence of stellar, mildly enhanced, infiltrative lesions in suggestive areas. The aim of this pictorial review is to provide an image-based overview of key findings for the diagnosis of acute abdominal complications of endometriosis. Critical relevance statement: This educational review provides an exhaustive overview of acute abdominal presentations of endometriosis along with illustrative examples, to facilitate their diagnosis in clinical practice. Key points: This review addresses key imaging findings of acute abdominal complication of endometriosis. Endometriosis must be considered in menstruating women presenting with acute abdominal pain. Magnetic Resonance Imaging plays a key role in the diagnosis. [ABSTRACT FROM AUTHOR]

Background: A urachal cyst has a rare incidence that has been reported as 1/5,000 live birth. Case presentation: We report two patients with a complicated urachal cyst, a 5-year-old female who presented to the emergency department with severe abdominal pain and a 3-year-old female presenting with abdominal pain and constipation. Upon laparoscopic exploration both patients had complicated urachal cysts which were adherent to the urinary bladder. Conclusion: Complicated urachal cysts can present with acute abdominal pain. [ABSTRACT FROM AUTHOR]

Acute appendicitis is the most common cause of acute abdominal pain presentations to the ED and common air ambulance transfer. Aims: describe how linked data can be used to explore patients' journeys, referral pathways and request-to-activation responsiveness of patients' appendectomy outcomes (minor vs major complexity). Data sources were linked: aeromedical, hospital and death. Request-to-activation intervals showed strong right-tailed skewness. Quantile regression examined whether the longest request-to-activation intervals were associated with appendicitis complexity in patients who underwent an appendectomy. There were 684 patients in three referral pathways based on hospital capability levels. In total, 5.6 % patients were discharged from ED. 83.3 % of all rural origins entered via the ED. 3.8 % of appendicitis patients were triaged to tertiary hospitals. Appendectomy patients with major complexity outcomes were less likely to have longer request-to-activation wait times & had longer lengths of stay than patients with minor complexity outcomes. Linked data highlighted four aspects of a functioning referral system: appendectomy outcomes of major complexity were less likely to have longer request-to-activation intervals compared to minor (sicker patients were identified); few were discharged from EDs (validated transfer); few were triaged to tertiary hospitals (appropriate level for need), and no deaths relating to appendectomy. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study was to determine outcomes in patients presenting to emergency department (ED) with acute abdominal pain and suspected occult myocardial injury [OMI (high-sensitive cardiac troponin T, hs-cTnT level > 14 ng/L)] without clinical signs of myocardial ischaemia. We hypothesized that OMI is a common entity associated with poor outcomes. Methods: After institutional research ethics committee approval, a retrospective review was performed on patients subjected to extended use of hs-cTnT measurements during two months period in patients admitted to ED with a chief complaint of abdominal pain, aged 30 years or older and triaged to red, orange, or yellow categories. Primary outcomes were 30-day, six-month, and one-year mortality, respectively. Adjusted mortality rates were compared using the Cox proportional hazard regression model. Results: Overall, 1000 consecutive patients were screened. A total of 375 patients were subjected to hs-cTnT measurement and 156 of them (41.6%) experienced OMI. None of the patients had acute myocardial infarction diagnosed in the ED. Patients with OMI had a significantly higher 30-day, six-month and one-year mortality compared to the normal hs-cTnT level group [12.8% (20/156) vs. 3.7% (8/219), p = 0.001, 34.0% (53/156) vs. 6.9% (15/219), p < 0.001 and 39.1% (61/156) vs. 9.1 (20/219), p < 0.001, respectively]. OMI was an independent risk factor for mortality at every time point analyzed. Conclusion: Our investigation noted OMI in older patients with co-morbidities and in higher triage category presenting with abdominal pain to ED, respectively. OMI is an independent risk factor for poor outcomes that warrants appropriate screening and management strategy. Our results support the use of hs-cTnT as a prognostication tool in this subgroup of ED patients. [ABSTRACT FROM AUTHOR]

Aim: Adnexal torsion remains a diagnostic challenge due to the nonspecific symptoms, sonographic features, and laboratory findings. The value of combining clinical, sonographic, and laboratory features is not well established, and controversy continues regarding their value in diagnosis. This study aimed to review sonographic, clinical, and laboratory features and to analyze their value separately and in combination, in managing and diagnosing adnexal torsions. Methods: The study included 278 women who underwent urgent laparoscopic surgery due to suspected adnexal torsion, according to clinical suspicion, with or without sonographic concordance. Laparoscopy findings confirmed the definitive diagnosis of torsion. Clinical laboratory and sonographic features were compared between those with and without adnexal torsion. Results: Adnexal torsion was confirmed in 110/278 (39.6%) women. In the torsion compared to nontorsion group, proportions were higher of women with acute abdominal pain in the preceding 24 h ([50] 45.5% vs. [35] 20.8%, p < 0.001), with vomiting ([45] 40.9% vs. [24] 14.3%, p < 0.001) and with suspected torsion by transvaginal sonography ([49] 44.5% vs. [23] 13.7%, p < 0.001). A high neutrophil‐to‐lymphocyte ratio (>3) was identified in 65 (59.1%) of the study group and 60 (35.7%) of the control group (p < 0.001). Combining the latter three findings, the predicted probability of torsion was 58%–85%, depending on the combinations. Conclusions: A simple predictive model based on combinations of clinical, laboratory, and sonographic findings can contribute to preoperative diagnosis of adnexal torsion, with predicted probability of 85%. Our model may assist clinicians in evaluating women with suspected adnexal torsion, and improve preoperative diagnostic accuracy. [ABSTRACT FROM AUTHOR]