Hemant Sheth

Hepatic Portal Venous Gas: Comparison of Two Cases

Context. Hepatic portal venous gas (HPVG) is a rare and sinister finding. Its mortality is associated with the underlying causative condition. When secondary to bowel ischaemia, mortality rates exceed 50%. Case Report. Two cases of HPVG are described. One case describes HPVG in association with gastric ischaemia, with complete resolution following conservative management. The second case describes HPVG in association with widespread intra-abdominal ischaemia, with resultant mortality. Conclusion. A “watch and wait” management of HPVG associated with gastric ischaemia is suggested in certain patients, with a low threshold for surgical intervention. HPVG associated with bowel ischaemia is an absolute indication for surgical intervention, where intervention may change the clinical course.

Vancomycin-induced thrombocytopaenia in a patient with severe pancreatitis

Vancomycin-induced thrombocytopenia is a rare side effect of a commonly used drug that may cause life-threatening disease. A 51-year-old man was treated for an episode of acute severe alcohol-induced pancreatitis complicated by development of a peripancreatic fluid collection. He developed fever of unknown origin and was treated with intravenous vancomycin and piperacillin with tazobactam. On day 6 of vancomycin therapy his platelet count dropped to 46×109/L (237×109/L on day 1 of treatment) and by day 8 of therapy platelets had fallen to a nadir of 9×109/L. The patient at this stage displayed a florid purpuric rash and haematoma formation on attempted intravenous cannulation. A clinical diagnosis of vancomycin-induced thrombocytopaenia was made and the drug withdrawn. After 3 days a significant improvement in the platelet count was noted, rising to 56 × 109/L. Immunofluorescence testing (PIFT) ruled out teicoplanin and heparin as causes of drug-induced thrombocytopenia.

Non-haemorrhagic, bilateral adrenal infarction in a patient with antiphospholipid syndrome along with lupus myocarditis.

A 40-year-old woman with antiphospholipid syndrome presented with a 5-day history of right upper quadrant (RUQ) pain, radiating posteriorly, associated with fever and vomiting. She was admitted 1-week prior with an upper respiratory infection and erythema multiforme. Clinical assessment revealed sepsis with RUQ tenderness and positive Murphys sign. Laboratory results showed raised inflammatory markers, along with renal and liver impairment. CT showed bilateral adrenal infarction and inferior vena cava thrombus. The patient was managed for sepsis and started on heparin. Further immunological investigations revealed a diagnosis of systemic lupus erythematous, an exacerbation of which culminated in lupus myocarditis. This case illustrates the importance of promptly recognising adrenal insufficiency in patients with antiphospholipid syndrome and the possible causative agents, which require careful consideration and exclusion to prevent further thrombotic events. It also highlights the importance of undertaking imaging, namely CT, in patients with antiphospholipid syndrome presenting with abdominal pain as well as considering concomitant autoimmune conditions.

The Diagnostic Utility and Clinical Impact of After-Hours CT Scans of the Abdomen and Pelvis Investigating Abdominal Pain

Introduction The aim of this study was to evaluate the diagnostic utility and impact on clinical management of after-hours CT scans investigating abdominal pain in surgical patients. Methods After-hours CT A/P reports investigating the acute surgical abdomen were compared with clinical outcomes and histopathological findings to assess sensitivity and specificity of CT reporting. Comparisons between CT reports and clinical notes were made. CT scans were categorised as having direct effects on clinical management, ruling out a serious pathology, ruling out a nonserious pathology, or having no effect. Discrepancies between information in case-notes and information provided to radiologists were also analysed. Results 79 clinical notes were located. After-hours CT demonstrated 91% sensitivity and 82% reporting specificity using clinical outcomes as the standard. In the 26 patients with histopathological findings, CT reports demonstrated 91% sensitivity. In 79.7% of cases, CT scanning had an impact on management. In 35.4% of cases, an indication for scanning was not documented with variation in clinical information in 8.9% of cases. Discussion This study demonstrates after-hours CT A/P reports result in significant impacts on clinical management of surgical patients with acute abdominal pain. Improvements in providing information when requesting scans are however needed to facilitate accurate reporting.

Primary Gallbladder Lymphoma in a Male Patient with No Risk Factors Detected Incidentally by CT Colonography.

Primary gallbladder lymphoma, although rare, usually presents in females with symptoms mimicking cholecystitis. We present a rare case of primary gallbladder in an 81-year-old male with no risk factors whose only symptom was weight loss. Routine blood tests including liver function tests were unremarkable. A CT colonography was carried out to exclude colonic malignancy. Unilateral gallbladder wall thickening and lymphadenopathy were incidentally detected and confirmed by ultrasound and a decision for the patient to undergo laparoscopic cholecystectomy and intraoperative cholangiogram was made. Histology confirmed extranodal marginal zone lymphoma with follow-up staging and biopsy of the bone marrow not demonstrating spread. Cholecystectomy was therefore deemed curative and no adjuvant therapy was necessary. Thickening of the gallbladder wall on any imaging with or without symptoms should not be ignored or assumed to be cholecystitis, even in males with no risk factors. In these patients urgent cholecystectomy with intraoperative cholangiogram is indicated with histology and haematology follow-up.

A case of emphysematous pyelonephritis

A 40-year-old Asian man admitted for treatment of diabetic ketoacidosis was referred to the on-call general surgical team with pain and tenderness over the right loin and renal angle. He had recently returned from India. The patient had a white cell count of 16.9 × 10/L, platelet count of 76 × 10/L, creatinine of 139 umol/L and C-reactive protein of 172 mg/L. Plain film radiography of the abdomen revealed a gas density on the outline of the right kidney (Fig. 1). An urgent non-contrast computed tomography (CT) scan of the abdomen demonstrated a large amount of gas within the right renal parenchyma with right-sided hydronephrosis and hydroureter (Fig. 2a,b). The diagnosis of emphysematous pyelonephritis was made. An 8-French locking pigtail nephrostomy was inserted percutaneously under ultrasound guidance. A 14-French locking pigtail catheter was inserted into the emphysematous region superiorly within the right kidney. Pus and urine were aspirated and cultures subsequently grew Enterobacter aerogenes. He was treated conservatively with intravenous antibiotics and supportive therapy within an intensive care setting and made a successful recovery. Emphysematous pyelonephritis is a rare, but life-threatening condition characterized by infection with gas-forming gram-negative bacteria within the renal parenchyma, most commonly by Escherichia coli. It is most frequently seen in women in the fourth or fifth decade and the majority of case series originate from Asia. The condition often presents on the background of poorly controlled diabetes. Loin pain is typical and patients may also complain of nausea, vomiting, dysuria and rigours. In this case, there was thrombocytopenia, acute kidney injury and decreased consciousness. Such features, as well as severe hypotension, hyponatremia and bilateral disease, have been associated with higher mortality rates. CT imaging is required for diagnosis and evaluation of the extent of disease. Emphysematous pyelonephritis may be treated conservatively with supportive therapy and antibiotics alone, with percutaneous drainage or through emergency nephrectomy. In 2008, a systematic review of available data, mostly retrospective reports of case series, demonstrated a 13.5% mortality in patients treated with percutaneous drainage compared with 25% and 50% mortality for conservative therapy and emergency nephrectomy, respectively. Further, those treated through percutaneous drainage may show up to 92%