Onder Limon

An unusual cause of death: spontaneous urinary bladder perforation

Spontaneous urinary bladder perforation is a rare and life-threatening condition similar to traumatic and iatrogenic perforation. The connection with the underlying bladder damage due to previous radiotherapy, inflammation, malignancy, obstruction, or other causes can be found in almost all cases. The symptoms are often nonspecific, and misdiagnosis is common. Here, we present a case of spontaneous urinary bladder perforation due to bladder necrosis in a diabetic woman. She presented to the emergency department with abdominal pain. Exploratory laparotomy was performed by surgeons and revealed necrosis of the anterior and lateral walls of the urinary bladder. Microscopic examination revealed necrotic changes throughout the bladder wall. Ghost-like cellular outlines were compatible with coagulative necrosis. Clusters of bacteria were also present in some necrobiotic tissues. Malignant cells were not present. It appears probable that the infection was due to local interference with the blood supply (arterial, capillary, or venous) combined with the systemic metabolic upset that led to the bladder condition. In our case, we observed partial necrosis of the bladder rather than distortion of the entire blood supply to the bladder as consequences of the microvascular effects of diabetes. Urinary bladder perforation must be considered in the differential diagnosis of patients presenting with free fluid in the abdomen/peritonitis, decreased urine output, and hematuria, and in whom increased levels of urea/creatinine are detected in serum and/ or peritoneal fluid aspirate.

Bibliometric analysis of top 100 most-cited clinical studies on ultrasound in the Emergency Department

STUDY OBJECTIVE We identify and characterize the most highly cited articles related to ultrasonographic evaluations occurring in the emergency department. METHOD We retrieved the top 100 articles in terms of citations pertaining to ultrasonographic evaluations in the emergency department from the Scopus database. We determined the number of citations of each article, the number of citations per year, the number of Google Scholar citations, the ultrasonographical study fields, the number of patients evaluated in each study, and the specialties of the researchers conducting the studies and ultrasonographies. We then used the ANOVA test to compare the multivariate groups. RESULTS The median citation number of the articles in the Scopus database was 115 (range: 75-681), and the number of citations per year was 7.5 (range: 3.8-40.1). Focused assessment with sonography in trauma and non-traumatic abdominal ultrasonography were conducted in 32 and 13 studies, respectively. The primary authors were emergency medicine specialists in 46 studies. We found that vascular and lung ultrasonography studies were characterized by the largest number of citations per year. CONCLUSION The most frequently cited studies conducted in the emergency department pertaining to the use of ultrasonography included a wide range of topics, and approximately half of the primary authors of these studies were emergency medicine specialists.

Retrospective evaluation of patients with elevated digoxin levels at an emergency department

Objectives We investigated the demographic characteristics, clinical and laboratory findings, treatment strategies and clinical outcomes of patients presenting at emergency department (ED) with digoxin levels at or above 1.2 ng/ml. Materials and methods The demographic and clinical characteristics of patients with serum digoxin levels at or above 1.2 ng/ml admitted to an ED between January 2010 and July 2011 were investigated in this cross-sectional descriptive study. Patients with ECG and clinical findings consistent with digoxin toxicity and no additional explanation of their symptoms were evaluated for digoxin toxicity. Results In this study 137 patients were included, and 68.6% of patients were women with mean age 76.1 ± 12.2. There was no significant difference between gender and digoxin intoxication. The mean age of intoxicated group was significantly higher than the non-intoxicated group (P = 0.03). The most common comorbidities were congestive heart failure (n = 91) and atrial fibrillation (n = 74). The most common symptoms were nausea, vomiting and abdominal pain. The levels of hospitalization and mortality in this group were significantly higher. Conclusion Digoxin intoxication must be suspected in patients present in the ED, particularly those with complaints that include nausea and vomiting, as well as new ECG changes; serum digoxin levels must be determined.

Acute pancreatitis due to extracorporeal shock wave lithotripsy: a rare complication

Extracorporeal shock wave lithotripsy (ESWL) is considered the treatment of choice for most renal and upper ureteral stones. Although extensive data have documented its safety, serious complications have been reported in 1% of patients, including acute pancreatitis, perirenal hematoma, urosepsis, venous thrombosis, biliary obstruction, bowel perforation, lung injury, and rupture of aortic aneurysms. Here, we report a 41-year-old woman who underwent ESWL for a calculus at the right renal pelvis and immediately developed acute pancreatitis after the procedure. Although the possibility of post-ESWL acute pancreatitisis extremely low, physicians must be aware of this complication in emergency departments.

A potential pitfall in the diagnosis of renal colic: renal infarction.

Renal infarction is a rarely seen clinical condition with a nonspecific presentation. It often presents as renal colic or an acute abdomen and is initially misdiagnosed. In patients who present to the emergency department (ED) with abdominal pain or flank pain resistant to treatment, renal infarction must be considered, especially if they have thromboembolic risk factors. Abdominal computerized tomography with intravenous contrast is the choice of imaging because of its high sensitivity. We report cases of 2 patients who presented to our ED with flank pain and hematuria. They were diagnosed with urethral colic from stones as an initial diagnosis. They were further evaluated for thromboembolic risk factors and persistent flank pain, and a final diagnosis of renal infarction was given. Renal infarction is a rare condition with a nonspecific presentation [1]. It is infrequently included in the differential diagnosis of abdominal and flank pain, and the diagnosis is often delayed [2,3]. Cases of renal infarction have been misdiagnosed as renal colic, nephrolithiasis, and acute abdomen. Patients with renal infarction most frequently present with abdominal pain, nausea, vomiting, and fever [1,4]. In half of the patients, the diagnosis is missed on initial presentation [1,3,5,6]. In many cases of renal infarction, the patient has a history of arrhythmia or valvular disease. We present 2 patients who came to the emergency department (ED) with renal colic and was given the diagnosis of renal infarction. With these cases, we discuss the clinical presentation, laboratory testing, and imaging techniques used to diagnose renal infarction. A 54-year-old woman presented to the ED with right flank pain radiating to the abdomen with onset 30 minutes This study has been accepted for poster presentation at The First Eurasian Congress on Emergency Medicine, November 5 to 9, 2008, in

Spontaneous Bladder Rupture and Pelvic Fracture Due To Bladder Cancer

SUMMARY Bladder rupture is a rare complication following bladder cancer, but has a high mortality rate. Since bladder rupture is an emergency, the diagnosis and treatment of the cancer is usually delayed. Here we report a 56-year-old male patient who presented to our emergency department with severe abdominal pain, abdominal distension, left leg pain and difficulty in walking without history of significant trauma and ended up with diagnoses of spontaneous bladder rupture and non-traumatic pelvic fracture caused by bladder carcinoma.

Acute Epiploic Appendicitis: A Diagnostic Dilemma

SUMMARY Primary epiploic appendicitis, also called appendicitis epiploica, is a rare condition characterized by inflammation of subserosal colonic adipose tissue. Patients with this condition usually present with complaints of sudden onset focal abdominal pain. No specific symptom or pathognomonic physical examination finding differentiates this condition from other acute abdominal pain etiologies. Patients are usually thought to have diverticulitis or appendicitis on initial evaluation. Use of contrast enhanced abdominal computed tomography on patients presenting with acute abdominal pain may reduce unnecessary surgery, hospitalization and health-associated costs by establishing a definite diagnosis, including rare causes of acute abdomen.

Laparoscopic resection for Meckel’s diverticulum causing intestinal obstruction

Meckels diverticulum (MD) is the most common congenital anomaly of the gastrointestinal system with an estimated incidence of approximately 2% of the population. Although most cases are asymptomatic, it has the potential to create complications, such as hemorrhage, inflammation, intestinal obstruction, perforation, and intussusception. Meckels diverticulum is generally diagnosed incidentally or upon investigation of unexplained gastrointestinal bleeding, perforation, inflammation, or obstruction for both pediatric and adult patients. Complications are often present as surgical emergencies and require resection of the diseased intestinal segment. In doubtful cases, laparoscopy should be the surgical method for both diagnosing and treating MD. Here we present a case of MD causing intestinal obstruction and that was treated by laparoscopic resection.

A rare entity in ED: Normal lipase level in acute pancreatitis

Acute pancreatitis can have a variable presentation and diagnosis is based on clinical presentation, serum amylase and lipase levels and computed tomography. Negative predictive value of serum lipase in diagnosing acute pancreatitis is approximately to 100 percent and a normal blood lipase level in acute pancreatitis is an extremely rare condition. Here we reported two cases with normal serum amylase and lipase levels.

Laparoscopic splenectomy for a wandering spleen causing chronic pelvic pain

Wandering spleen is a rare condition with a reported incidence of less than 0.5% in which the spleen migrates from its normal anatomical location to any other position in the abdomen. Women constitute 80% of cases and one third of the overall patients are children. It has different clinical presentations such as asymptomatic, painless mass in the abdomen, intermittent abdominal pain and acute abdomen due to torsion of the vascular pedicle. Here we present a case of wandering spleen causing chronic pelvic pain. Laparoscopic splenopexy was the treatment choice but it could not be performed due to huge size of the wandering spleen.