Min-Po Ho

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

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Delayed discovery and diagnosis of achalasia resulting in megaesophagus in an elderly nursing home resident.

New-onset headaches in adults aged 65 and older are rare, accounting for only 5.4% of all new-onset headaches, but elderly adults with new-onset headaches have a risk of serious conditions, such as stroke, malignancy, infection, or temporal arteritis (15% ≥65 vs 1.6% <65) that is 10 times as great as in younger individuals. Cryptococcal meningitis, with an incidence of 3.3% in adults aged 70 and older, is rarely suspected in elderly adults. Additionally, 30% of all cryptococcal meningitis cases had no apparent underlying cause or identifiable risk factors. The patient described in throughout saw 16 providers over 8 days before the correct diagnosis was made. The diagnostic process was challenging, because her only presenting symptom was headache, and her only risk factor was low-dose corticosteroids. ED physicians typically see younger individuals whose headaches are often benign. Because providers were unaware that new-onset headaches in elderly adults are likely caused by serious conditions, head CT and lumbar puncture were delayed until she developed a fever. Because cryptococcal meningitis was not suspected, opening pressure and cryptococcal antigen and culture were not checked until Day 9. India ink on the initial lumbar puncture provided a false sense of security, because it has only 50% sensitivity in HIV-negative individuals and cannot be used as a rule-out test.

Bacterial Infections in Patients with Liver Cirrhosis

Bacterial infections are common and severe complication of liver cirrhosis which is frequently encountered in the emergency department and hospitalized cirrhotic patients. The most frequent infections include spontaneous bacterial peritonitis, pneumonia, urinary tract infections, and bacteremia. Cirrhotic patients are particularly susceptible to bacterial infections because of increased bacterial translocation, possibly related to liver dysfunction and reduced reticuloendothelial function, and iatrogenic factors. In fact, the in-hospital mortality of cirrhotic patients with infections is approximately 15%, more than twice that of patients without infection. In this article, we provide a brief overview of the epidemiology, manifestations, management and prophylaxis of these complications in cirrhotic patients.

Incarcerated Incisional Hernia: Strangulated Transverse Colon with Perforation Associated with Abscess Formation

We wish to thank Mrs. Aki Watanabe and Mrs. Naoko Koizumi, Department of Clinical Cell Biology and Medicine, Chiba University Graduate School of Medicine, for their valuable technical assistance. This work was supported by the Health and Labour Sciences Research Grants from the Ministry of Health, Labour and Welfare of Japan for the Research on Measures for Intractable Diseases. Conflict of interest: All authors have no conflict of interests. Author Contributions: Ide, Yamamoto, Fujimoto: data analysis and interpretation, acquisition of subjects and data. Takemoto: data interpretation, manuscript preparation. Ide, Kobayashi: data acquisition. Yokote: discussion, review and editing of manuscript. Sponsor’s Role: The sponsor had no role in this study.

Delayed herniation of intra-abdominal contents after blunt right-sided diaphragm rupture

Right diaphragmatic hernia is a rare injury (0.25%-1%) after blunt abdominal trauma. The diagnosis may be delayed and achieved years after the trauma. We currently report a case of a 48-year-old man who presented to the emergency department at Far Eastern Memorial Hospital, New Taipei City, Taiwan, demonstrating signs of herniation of the right diaphragm. The herniation was confirmed using a chest radiograph. The patient reported falling 3 years before the current evaluation and was symptom-free before arrival in the emergency department. The diagnosis was further confirmed through thoracoabdominal computed tomography. The diaphragmatic hernia was subsequently repaired via abdominal approach. For patients with a history of prior thoracoabdominal trauma with complaints of new abdominal pain, a delayed diaphragmatic hernia should be considered.

Hepatocellular Carcinoma with Invasion into the Right Atrium: A Case Report

Hepatocellular carcinoma (HCC) has a great tendency toward venous invasion; however, metastatic HCC invasion into the right atrial cavity was rarely reported. We herein report a rare case of right atrial invasion from hepatocellular carcinoma in a 50-year-old man with history of alcoholic liver cirrhosis, and later diagnosed as hepatocellular carcinoma. Because of the patient did not wish any invasive therapy, he received compassionate thalidomide therapy only. Two weeks later, he died of circulatory collapse. Cardiac involvement of HCC should be considered when a patient with a history of chronic hepatic disease presents with unexplained cardiac symptoms or refractive leg edema. Keeping a low threshold for cardiac image surveillance is suggested.

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.