Kuang-Chau Tsai

SPONTANEOUS INTRAMURAL SMALL BOWEL HEMATOMA ASSOCIATED WITH WARFARIN NONADHERENCE IN AN ELDERLY PATIENT

1. Libow LS. Geriatrics in the United StatesFbaby boomer’s boon? N Engl J Med 2005;352:750–752. 2. McCabe WR, Jackson GG. Gram negative bacteremia: Etiology and ecology. Arch Intern Med 1962;29:2132–2139. 3. Knaus WA, Zimmerman JE, Wagner DP et al. APACHE Acute Physiology And Chronic Health Evaluation: A physiologically based classification system. Crit Care Med 1981;9:591–597. 4. Katz S, Ford AB, Moskowitz RWet al. Studies of illness in the aged. The index of ADL: A standardized measure of biological and psychosocial function. JAMA 1963;185:914–919. 5. Le Gall JR, Loirat P, Alperovitch A et al. A simplified acute physiology score for ICU patients. Crit Care Med 1984;12:185–190. 6. Leroy C, Ricard-Hibon A, Chollet C et al. Out-of-hospital management of elderly patients. Ann Fr Anesth Reanim 2003;22:183–189. 7. Duchateau FX, Burnod A, Dahmani S et al. Out-of-hospital interventions by the French Emergency Medical Service are associated with a high survival in patients aged 80 year or over. Intensive Care Med 2008;34:1544–1545.

Pneumoretroperitoneum, pneumoperitoneum, pneumomediastinum, pneumopericardium and subcutaneous emphysema after endoscopic mucosal resection in an older adult

A 67-year-old man presented to the emergency department with fever and chills lasting 1 day after colonoscopy, which showed a 2-cm laterally spreading tumor at the ascending colon, and an endoscopic mucosal resection was carried out. His past medical history was significant for controlled hypertension. He was febrile, with a temperature of 37.8 C. His abdomen was soft without rebound pain. A chest radiograph showed subcutaneous emphysema (thick arrows), pneumomediastinum (thin arrow) and subdiaphragmatic free air (arrowhead; Fig. 1a). Computed tomography of the abdomen showed diffuse pneumoretroperitoneum (thick arrows, Fig. 1b), especially hepatic flexure of the colon, with pneumomediastinum (thin arrow, Fig. 1c), pneumopericardium (thin arrow, Fig. 1b) and subcutaneous emphysema in the right thoracoabdominal wall (thick arrows, Fig. 1a–c). According to the patient’s history, physical examination and the imaging findings, a diagnosis of pneumoretroperitoneum, pneumomediastinum, pneumoperitoneum, pneumopericardium and subcutaneous emphysema was made after endoscopic mucosal resection was carried out. Therefore, we concluded that the type of perforation was a combined type of intraperitoneal and extraperitoneal perforation. The patient’s treatment plan included endoscopic clipping, nothing by mouth, intravenous fluid hydration and intravenous antibiotics, such as flomoxef sodium for 4 days; treatment was successful. The complications of colonoscopy include bleeding, perforation and postpolypectomy coagulation syndrome. Among these complications, perforation is most common, ranging from 0.4% to 1.9%. A previous study reported that perforation was more common with therapeutic colonoscopy when compared with that of diagnostic colonoscopy (0.44% vs 0.16%). Colonic perforation might be intraperitoneal, extraperitoneal or both. Right subdiaphragmatic free air develops in an intraperitoneal perforation, whereas pneumoretroperitoneum, pneumomediastinum, pneumopericardium and subcutaneous emphysema suggest extraperitoneal perforation. Maunder et al. described the route of extraperitoneal gas. The soft tissue compartment of the neck, thorax and abdomen contains four regions: the subcutaneous tissue, prevertebral tissue, visceral space and previsceral space. All of these spaces are connected along the neck, chest and abdomen. Therefore, air leakage in one space can easily spread to the others. Causes of perforation (excessive air insufflation, instrumental trauma, improper use of electrocautery) and risk factors for perforation (advanced age; medical comorbidity; therapeutic procedures, such as polypectomy, pneumatic dilation and endoscopic mucosal resection) have been described. Hamdani et al. reported older age, female sex, low body mass index, co-existent diseases and low albumen levels as risk factors of increased perforation rates in hospitalized patients, especially among those admitted to the intensive care unit. In terms of indications, perforation rates have been found to be higher during procedures carried out for diagnosing abdominal pain, anemia, Crohn’s disease and bleeding. Patients aged >75 years also have an approximately fourto sixfold rise in the colonic perforation rate, as opposed to younger patients. Possible explanations for an increased rate of colonic perforation in patients with advanced age include the fact that older adults have a declining colonic wall mechanical strength, as recognized in colonic diverticular diseases, and they often have a greater frequency of abnormal colorectal findings that might require endoscopic intervention. Extraperitoneal colonoscopic perforation is most likely to occur in the lower rectum. Otherwise, perforation of the ascending colon will cause mainly intraperitoneal free air. The ascending colon is basically recognized as an intraperitoneal organ, but a partially retroperitoneal organ. Therefore, perforation of the ascending colon possibly involves both (including retroperitoneal air leakage), which is why extraperitoneal air leakage is the main route. Furthermore, the vital signs and condition of the present patient were stable without peritonitis. That is why we decided to treat him with endoscopic clipping followed by conservative management including antibiotics, such as intravenous flomoxef sodium, to cover

Emphysematous cystitis in an elderly diabetic patient

Emphysematous cystitis (EC) is a rare urinary tract infection caused by gas-producing bacteria colonizing the urinary bladder. It is characterized by the presence of air within the urinary bladder wall and/or the presence of intraluminal air within the bladder. Diabetic and female patients are at highest risk of developing EC. A 74 year-old women presented to the emergency room with lower abdominal pain for 5 days. She had a history of diabetes mellitus, hypertension and chronic subdural hemorrhage postoperation status with chronic bedridden condition. Physical examinations showed only lower abdominal pain without rebound tenderness. Laboratory data showed blood sugar 253 mg/dL, white cell count 15610/cumm and otherwise normal ranges. Urine analysis showed red blood cells 1901/HPF and white blood cells 45/HPF. Plain radiograph showed one thin line of air around the urinary bladder (Fig. 1a). Computed tomography of the abdomen and pelvis showed gas bubbles within the wall of the urinary bladder that was diagnostic for emphysematous cystitis (Fig. 1b,c). Urinary culture was obtained and a urethral Foley catheter was inserted. Urine culture grew Escherichia coli, and based on the sensitivity, ceftriazone treatment was initiated. Her symptoms improved with our treatment, and she was discharged 14 days after admission. Emphysematous cystitis is a rare infection of the urinary bladder produced by gas-forming uropathogens. E. coli and Klebsiella pneumonia are the predominant pathogens. The major risk factor is diabetes mellitus. It can be seen as a rare complication of lower urinary tract infections. Typical symptoms are similar to those of uncomplicated urinary tract infections, including dysuria, hematuria, urinary frequency, fever and possible suprapubic pain. Pneumaturia, although more specific, is a much less common presenting symptom. Some patients might be completely asymptomatic at the time of incidental diagnosis. Although the overall incidence of emphysematous cystitis is unknown, it has a female predominance (female-to-male ratio, 2:1). Other predisposing risk factors include being elderly or debilitated, bladder outlet obstruction, chronic urinary tract infections, neurogenic bladder, chronic indwelling bladder catheters and immune deficiency. The majority of emphysematous cystitis cases (>60–70%) are caused by E. coli, as in the present case. Other common bacterial pathogens include Enterobacter species,K. pneumoniae, Staphylococcus aureus, Proteus mirabilis, Pseudomonas aeruginosa and Streptococcus species. Fungal agents, such as Candida species, are a less common cause. Abdominal pain is reported in 80% of cases, with hematuria in 47.6% of cases and fever in 47.6% of cases. Abdominal radiography is extremely sensitive (97.4%), although computed tomography is the most sensitive and specific tool for diagnosis. Themanagement of EC has remained unchanged over the past 30 years, with broad-cover intravenous antibiotics being used until urinary pathogen sensitivities are known. Concurrently, the bladder should be drained and blood glucose levels should be controlled. Between 10 and 20% of documented patients with EC underwent surgical debridement. In conclusion, clinical subcutaneous emphysema is a rare complication of EC that appears to have poor prognosis. Only careful clinical judgment, and a high degree of suspicion, will lead to its early diagnosis and treatment. Emergency physicians should know the radiological and variable clinical findings of EC, especially for diabetic elderly patients.

Ruptured Huge Internal Iliac Artery Aneurysm in an Elderly Adult

hyponatremia after administration of multiple doses of intravenous DDVAP have been reported. In the current case, a single dose caused prolonged hyponatremia. An examination of the prevalence of hyponatremia and the risk factors for hyponatremia in individuals taking oral DDVAP for nocturia found that basal sodium level and age were independently associated with development of hyponatremia; dose of DDVAP was not associated with hyponatremia. Older people have greater risk of hyponatremia because of changes with aging. Comorbidities and medications are additional risk factors for hyponatremia in older people taking DDVAP. Concomitant use of potentially harmful drugs such as diuretics and selective serotonin reuptake inhibitors with DDVAP was reported in a study from Sweden. Hydrochlorothiazide use may have contributed to hyponatremia in the current case, and the woman did not follow fluid restriction after DDVAP infusion. It is important that individuals being treated with DDVAP restrict fluids. In conclusion, physicians should not overlook this potential side effect of DDVAP in older people. Although DDAVP is seen as safe, older people may be prone to the side effects of DDAVP. Even one dose of DDVAP can induce hyponatremia in this population. In addition, some older people consume large amounts of water daily for a healthy lifestyle. Thus, it is important to question the amount of water intake before initiating DDAVP therapy, and water restriction should be recommended if necessary. Another important point is to check serum sodium concentration before initiating DDVAP and regularly after DDAVP therapy.

Gas-forming Pyogenic Liver Abscess: A Case Report

Gas-forming pyogenic liver abscess is considered to be a very severe form of pyogenic liver abscess and carries a high mortality. Klebsiella pneumoniae is the most common pathogen responsible for the disease. We present a case of gas-forming pyogenic liver abscess in a 53-year-old man with diabetic mellitus. The patient got improved with utilizing ultrasound guided percutaneous drainage, third generation cephalosporin and insulin control for hyperglycemia. He was discharged uneventfully after a 12-day hospitalization.

Cough-induced Rib Fracture: An Unusual Cause of Acute Chest Pain

Cough is one of the most common symptoms for which patients seek medical assistance. Usually, patients with cough recover without significant sequelae; however, violent cough can occasionally lead to complications such as pneumothorax and rib fracture. We reported a 34-year-old man who presented to our Emergency Department with intermittent non-productive cough for 2 weeks and sudden onset of right cheat pain after an episode of violent paroxysmal cough. The initial chest radiograph revealed no abnormality. The subsequent chest computed tomography demonstrated linear non-displacement fracture at lateral aspect of right seventh rib. Cough-induced fracture of the rib should be suspected in a patient who presents with prolonged or severe coughing and abrupt onset of chest pain after cough.

Chlorine Gas Exposure Manifesting Acute Lung Injury

Unintentional exposure to chlorine at swimming pools is not uncommon and can occur through various exposure scenarios, such as chlorine leak from pipes or reservoirs, or inappropriate flushing of chlorination/sanitation lines. Although mixing bleach (sodium hypochlorite) with acids accounts for many household chlorine exposure accidents, such an exposure is rare at swimming pools. Clinical manifestations of chlorine inhalation can range from mild upper airway irritation to life-threatening toxic effects, such as pulmonary edema/acute respiratory distress syndrome. We reported an incident of chlorine exposure generated from mixing sodium hypochlorite and hydrochloric acid at a swimming pool. Among the 7 victims, 6 presented with dyspnea, dry cough, sore throat and eye irritation. These six patients were discharged within 1 day. A 15-year-old girl however developed hypoxemia and acute lung injury primarily involved right middle and lower lungs in addition to symptoms of airway irritation. She was discharged 5 days later after receiving both bronchodilator and intravenous steroid therapy. Her clinical manifestations were discussed along with a review of existing literature reports on chlorine inhalation.

POSTRENAL BIOPSY HEMATOMA IN AN ELDERLY PATIENT

ACKNOWLEDGMENTS Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. This work was fully supported by Ministero della Salute, IRCCS Research Program, Ricerca Corrente 2009-2011, Linea n. 2 Malattie complesse. Author Contributions: Solfrizzi and Panza: concept, interpretation, and manuscript preparation. Frisardi, Seripa, and Pilotto: interpretation and manuscript preparation. Sponsor’s Role: The funding agency had no role in design or conduct of the study.

The Advantage of Contrast-enhanced Helical Computed Tomography in the Diagnosis of Arterio-enteric Fistula in an Elderly Patient

■Arterio-enteric fistula is a rare but critical cause of gastrointestinal bleeding. Most of the cases in the literature resulted from complications of aortoiliac surgery 1 . A few cases developed in patients who had pelvic irradiation 2 or non-Hodgkin’s lymphoma 3 . Very rarely, the fistula occurred in patients with advanced ovarian cancer 4 . We report a case of advanced ovarian cancer with gastrointestinal bleeding caused by a rare arterioenteric fistula that was initially overlooked on angiography but correctly diagnosed on contrast-enhanced helical computed tomography (CT), which seems to be a useful tool for detecting unusual bleeders and is usually available in the emergency room. A 66-year-old female presented to our emergency department because of continuously massive anal bleeding. She was diagnosed with a stage IIIc ovarian adenocarcinoma with peritoneal carcinomatosis 2 years prior to this admission. She had received maximal debulking surgery and six cycles of chemotherapy. Upon arrival, her body temperature was 37.9°C, pulse rate was 156 beats/min, respiratory rate was 24 breaths/min, and blood pressure was 40/31 mmHg. Laboratory data showed a hemoglobin level of 6.7 g/dL and a white cell count of 17,200/mm 3 with a left shift. Prolonged prothrombin time and partial thromboplastin time were noted. The patient received fluid resuscitation, a blood transfusion, and empirical antibiotics. After stabilization of her vital signs, she underwent an emergency angiography in which no active bleeder was identified from the gastroduodenal artery, superior mesenteric artery or inferior mesenteric artery. A pelvic angiography showed an aneurysm in the left external iliac artery but without evidence of bleeding (Figure A). Despite medical stabilization, the bleed from the lower gastrointestinal tract persisted. A contrast-enhanced helical CT of the abdomen was subsequently performed in which a pooling of contrast material from the left external iliac artery was also seen (Figure B). This abnormal pooling of contrast material then drained into the sigmoid colon (Figure C). Owing to suspicion of an arterio-enteric fistula between the left external iliac artery and sigmoid colon, an emergent operation was performed. The surgical ligation was successful; however, a massive amount of infected bloody ascites was found. Two months after admission, she died of sepsis and multiple organ failure despite aggressive treatment. The predominant causes of lower gastrointestinal bleeding are diverticulitis, ischemic colitis, hemorrhoids, and arteriovenous malformations 5 . Poor control of active hemorrhage occurred in 37% of patients, and the mortality rate due to rebleeding could be as high as 3.5% of all cases of lower gastrointestinal bleeding 5 . It

Diphenhydramine Overdose Related Delirium: A Case Report

Diphenhydramine (DPHM) overdose is one of the most common causes of acute poisoning encountered in the emergency department. DPHM possesses both anticholinergic and sedative effects. Many authors have reported that topical and oral doses have led to hallucinatory psychosis, delirium, wide-complex tachycardia, hyperthermia, seizures and rhabdomyalysis, and the well-known anticholinergic syndrome has been well documented. We report on a young female patient who presented with delirium after ingesting 24 pills (one pill contains 50 mg) of DPHM to attempt suicide. Although the patient was treated with early gastric emptying followed by activated charcoal and general supportive care, she developed mental confusion, disorientation and short-term memory loss three hours after ingestion of DPHM. These symptoms subsided about seven hours after ingestion without neuropsychiatric sequalae.