PURPOSE: This study aimed to evaluate the clinical and radiologic findings suggestive of spontaneous intestinal perforation (SIP) in extremely-low-birth-weight infants (ELBWIs) with persistent gasless abdomen, and to investigate the usefulness of abdominal ultrasonography for the diagnosis of SIP. METHODS: In total, 22 infants with birth weights less than 1,000 g who showed persistent gasless abdomen on simple abdominal radiography were included. Perinatal, neonatal, and perioperative clinical findings were retrospectively reviewed, and the risk factors for intestinal perforation were evaluated. Abdominal sonographic findings suggestive of intestinal perforation were also identified, and postoperative short-term outcomes were evaluated. RESULTS: In total, eight of the 22 infants (36.4%) with gasless abdomen had SIP. The number of infants with patent ductus arteriosus who were treated with intravenous ibuprofen or indomethacin was significantly higher in the SIP group than in the non-SIP group (P<0.05). Greenish or red gastric residue, abdominal distension, or decreased bowel sound were more frequent in infants with SIP (P<0.05), in addition to gray or bluish discoloration of abdomen, suggestive of meconium peritonitis (P<0.05). Pneumoperitoneum on simple abdominal radiography was found in only one of the eight infants (12.5%) with SIP. Intramural echogenicity and echogenic extramural material on abdominal ultrasonography were exclusively observed in infants with SIP. Four infants (50%) with SIP died after surgical intervention. CONCLUSION: Intestinal perforation may occur in ELBWIs with gasless abdomen. As intramural echogenicity and extraluminal echogenic materials on abdominal ultrasonography are indicative of SIP, this technique could be useful for diagnosing SIP.
Abdomen ; Birth Weight ; Diagnosis ; Ductus Arteriosus, Patent ; Humans ; Ibuprofen ; Indomethacin ; Infant ; Infant, Extremely Low Birth Weight ; Infant, Low Birth Weight ; Infant, Newborn ; Intestinal Perforation ; Meconium ; Peritonitis ; Pneumoperitoneum ; Radiography, Abdominal ; Retrospective Studies ; Risk Factors ; Ultrasonography

This paper presents a case report of tension pneumoperitoneum that occurred in a 4-month-old girl with intussusception during pneumatic reduction. Tension pneumoperitoneum is a rare but life threatening complication in air pressure enema that is commonly used to turn the intussuscepted bowel to its original position. The incidence of a simple pneumoperitoneum due to a bowel perforation associated with attempted pneumatic reduction for intussusception is as high as 4%. The simple pneumoperitoneum changed rapidly to tension pneumoperitoneum and immediate needle decompression was life-saving in this case. Similar to a tension pneumothorax, the diagnosis is clinical and management should not be delayed awaiting other confirmatory tests. The emergency physician must recognize this rare complication of pneumatic reduction and promptly treat the ensuing tension pneumoperitoneum after bowel perforation with immediate needle decompression as a part of the initial resuscitation.
Air Pressure ; Decompression ; Diagnosis ; Emergencies ; Enema ; Female ; Humans ; Incidence ; Infant ; Intussusception* ; Needles ; Pneumoperitoneum* ; Pneumothorax ; Resuscitation

Small bowel diverticulosis is a rare finding within all bowel diverticuloses and jejunal diverticulosis is even rarer. Their relative clinical rarity and varied presentation may make diagnosis both delayed and difficult. We experienced a case of jejunal diverticulosis, which was diagnosed intraoperatively. A 55-year-old woman was admitted to Emergency Department with pneumoperitoneum on plain chest and abdominal film from a local clinic. She was hemodynamically stable with minimal tenderness on the left upper quadrant of the abdomen but no rebound tenderness. At surgery, small bowel torsion and jejunal diverticulosis were confirmed. Over 30 variable sized small bowel diverticula were noted on the mesenteric side of the proximal jejunum. The affected segment of the jejunum was about 180 cm. On exploration, we could not find any perforation site. No postoperative complications were observed, and the patient made a full recovery. Jejunal diverticulosis is rare, but it should not be regarded as insignificant.
Abdomen ; Diagnosis ; Diverticulum* ; Emergency Service, Hospital ; Female ; Humans ; Jejunum ; Middle Aged ; Pneumoperitoneum* ; Postoperative Complications ; Thorax

Giant hiatal hernia (GHH) comprises 5% of hiatal hernia and is associated with significant complications. The traditional operative procedure, no matter transthoracic or transabdomen repair of giant hiatal hernia, is characteristic of more invasion and more complications. Although laparoscopic repair as a minimally invasive surgery is accepted, a part of patients can not tolerate pneumoperitoneum because of combination with cardiopulmonary diseases or severe posterior mediastinal and neck emphesema during operation. The aim of this article was to analyze our experience in gasless laparoscopic repair with abdominal wall lifting to treat the giant hiatal hernia. We performed a retrospective review of patients undergoing gasless laparoscopic repair of GHH with abdominal wall lifting from 2012 to 2015 at our institution. The GHH was defined as greater than one-third of the stomach in the chest. Gasless laparoscopic repair of GHH with abdominal wall lifting was attempted in 27 patients. Mean age was 67 years. The results showed that there were no conversions to open surgery and no intraoperative deaths. The mean duration of operation was 100 min (range: 90-130 min). One-side pleura was injured in 4 cases (14.8%). The mean postoperative length of stay was 4 days (range: 3-7 days). Median follow- up was 26 months (range: 6-38 months). Transient dysphagia for solid food occurred in three patients (11.1%), and this symptom disappeared within three months. There was one patient with recurrent hiatal hernia who was reoperated on. Two patients still complained of heartburn three months after surgery. Neither reoperation nor endoscopic treatment due to signs of postoperative esophageal stenosis was required in any patient. Totally, satisfactory outcome was reported in 88.9% patients. It was concluded that the gasless laparoscopic approach with abdominal wall lifting to the repair of GHH is feasible, safe, and effective for the patients who cannot tolerate the pneumoperitoneum.
Abdominal Wall ; surgery ; Aged ; Esophageal Stenosis ; etiology ; Female ; Fundoplication ; adverse effects ; methods ; Heartburn ; etiology ; Hernia, Hiatal ; diagnosis ; surgery ; Humans ; Laparoscopy ; adverse effects ; methods ; Male ; Middle Aged ; Pneumoperitoneum, Artificial ; adverse effects ; Postoperative Complications

Most of the congenital diaphragmatic hernia (CDH) cases are diagnosed at prenatal period or immediately after birth with severe respiratory symptom. The classic triad, which is respiratory distress, apparent dextrocardia and a scaphoid abdomen, is usually seen in this period. Several case reports have described older infants and children with a wide spectrum of symptoms of CDH, whereas extremely few cases were reported in neonatal period except classic triad such as straungulation of the bowel. These atypical manifestations can lead physician to delayed diagnosis. We report two cases of CDH newborns. First case was diagnosed with pneumoperitoneum following tension pneumothorax, transient diaphragm eventration on 5 days after birth. The other case was diagnosed with failure to thrive and mediastinal mass on 30 days after birth. These cases suggest physicians to consider CDH in late newborn period with pneumoperitoneum following tension pneumothorax, transient diaphragm eventration, failure to thrive, and mediastinal mass.
Abdomen ; Child ; Delayed Diagnosis ; Dextrocardia ; Diaphragmatic Eventration ; Failure to Thrive ; Hernia, Diaphragmatic* ; Humans ; Infant ; Infant, Newborn* ; Parturition ; Pneumoperitoneum ; Pneumothorax

BACKGROUNDS/AIMS: Pneumatosis intestinalis (PI) is a condition in which multiple gas-filled mural cysts develop in the gastrointestinal tract. Although its exact etiology remains obscure, PI is rarely observed in liver transplant (LT) recipients. METHODS: In 317 cases of adult living donor LT (LDLT) performed during 2011, PI developed in three patients during the 3 year follow-up. RESULTS: Of these three patients, the two who demonstrated PI at 6 weeks and 2 months after LT, respectively, were asymptomatic and showed no signs of secondary complications. Diagnosis was made incidentally using abdominal radiographs and computed tomography (CT) scans. PI was identified in the right ascending colon with concomitant pneumoperitoneum. These two patients received supportive care and maintained a regular diet. Follow-up CT scans demonstrated spontaneous resolution of PI with no complications. The third patient was admitted to the emergency room 30 months after LDLT. His symptoms included poor oral intake and intermittent abdominal pain with no passage of gas. Abdominal radiography and CT scans demonstrated PI in the entire small bowel, with small bowel dilatation, pneumoperitoneum, and pneumoretroperitoneum, but no peritonitis. Physical examination revealed abdominal distension but no tenderness or rebound tenderness. After 1 week of conservative treatment, including bowel rest and antibiotics therapy, PI and pneumoperitoneum resolved spontaneously without complications. CONCLUSIONS: We suggest that adult LDLT recipients who develop asymptomatic or symptomatic PI with no signs of secondary complications can be successfully managed with conservative treatment.
Abdominal Pain ; Adult* ; Anti-Bacterial Agents ; Colon, Ascending ; Diagnosis ; Diet ; Dilatation ; Emergency Service, Hospital ; Follow-Up Studies ; Gastrointestinal Tract ; Humans ; Liver ; Liver Transplantation* ; Living Donors* ; Peritonitis ; Physical Examination ; Pneumoperitoneum ; Radiography, Abdominal ; Retropneumoperitoneum ; Tomography, X-Ray Computed

PURPOSE: In this study, we aimed to review the clinical presentation of preterm infants with gastrointestinal perforations and compare the clinical features of gastric perforation with other intestinal perforations. METHODS: The medical records of preterm neonates with pneumoperitoneum, admitted to the neonatal intensive care unit (NICU) between January 1994 and December 2013, were retrospectively reviewed. RESULTS: Twenty-one preterm infants underwent exploratory laparotomy to investigate the cause of the pneumoperitoneum. The sample consisted of five patients (23.8%) with gastric perforation and 16 patients (76.2%) with intestinal perforation. No statistical differences were found in the birth history and other perinatal factors between the two groups. Underlying necrotizing enterocolitis, bilious vomiting, and paralytic ileus preceding the perforation were statistically more common in the intestinal perforation group. All preterm infants with gastric perforation survived to discharge; however, six preterm infants with intestinal perforation expired during treatment in the NICU. In the gastric perforation group, sudden pneumoperitoneum was the most common finding, and the mean age at diagnosis was 4.4+/-1.7 days of life. The location and size of the perforations varied, and simple closure or partial gastrectomy was performed. CONCLUSION: Patients with gastric perforation did not have a common clinical finding preceding the perforation diagnosis. Although mortality in previous studies was high, all patients survived to discharge in the present study. When a preterm infant aged less than one week presents with sudden abdominal distension and pneumoperitoneum, gastric perforation should first be excluded. Prompt exploratory laparotomy will increase the survival rates of these infants.
Diagnosis ; Enterocolitis, Necrotizing ; Gastrectomy ; Humans ; Infant ; Infant, Newborn ; Infant, Premature* ; Intensive Care, Neonatal ; Intestinal Perforation ; Intestinal Pseudo-Obstruction ; Laparotomy ; Medical Records ; Mortality ; Pneumoperitoneum ; Reproductive History ; Retrospective Studies ; Stomach Rupture ; Survival Rate ; Vomiting

BACKGROUND/AIMS: Endoscopic ultrasound-guided fine needle aspiration and/or biopsy (EUS-FNA/B) have been used to diagnose subepithelial tumors (SETs) and extraluminal lesions in the gastrointestinal tract. Our group previously reported the usefulness of EUS-FNA/B for rectal and perirectal lesions. This study reports our expanded experience with EUS-FNA/B for rectal and perirectal lesions in terms of diagnostic accuracy and safety. We also included our new experience with EUS-FNB using the recently introduced ProCore needle. METHODS: From April 2009 to March 2014, EUS-FNA/B for rectal and perirectal lesions was performed in 30 consecutive patients. We evaluated EUS-FNA/B performance by comparing histological diagnoses with final results. We also investigated factors affecting diagnostic accuracy. RESULTS: Among 10 patients with SETs, EUS-FNA/B specimen results revealed a gastrointestinal stromal tumor in 4 patients and malignant lymphoma in 1 patient. The diagnostic accuracy of EUS-FNA/B was 50% for SETs (5/10). Among 20 patients with non-SET lesions, 8 patients were diagnosed with malignant disease and 7 were diagnosed with benign disease based on both EUS-FNA/B and the final results. The diagnostic accuracy of EUS-FNA/B for non-SET lesions was 75% (15/20). The size of lesions was the only factor related to diagnostic accuracy (P=0.027). Two complications of mild fever and asymptomatic pneumoperitoneum occurred after EUS-FNA/B. CONCLUSIONS: The overall diagnostic accuracy of EUS-FNA/B for rectal and perirectal lesions was 67% (20/30). EUS-FNA/B is a clinically useful method for cytological and histological diagnoses of rectal and perirectal lesions.
Biopsy* ; Biopsy, Fine-Needle ; Diagnosis ; Endoscopic Ultrasound-Guided Fine Needle Aspiration* ; Fever ; Gastrointestinal Stromal Tumors ; Gastrointestinal Tract ; Humans ; Lymphoma ; Needles ; Pneumoperitoneum ; Rectum

BACKGROUND/AIMS: Endoscopic ultrasound-guided fine needle aspiration and/or biopsy (EUS-FNA/B) have been used to diagnose subepithelial tumors (SETs) and extraluminal lesions in the gastrointestinal tract. Our group previously reported the usefulness of EUS-FNA/B for rectal and perirectal lesions. This study reports our expanded experience with EUS-FNA/B for rectal and perirectal lesions in terms of diagnostic accuracy and safety. We also included our new experience with EUS-FNB using the recently introduced ProCore needle. METHODS: From April 2009 to March 2014, EUS-FNA/B for rectal and perirectal lesions was performed in 30 consecutive patients. We evaluated EUS-FNA/B performance by comparing histological diagnoses with final results. We also investigated factors affecting diagnostic accuracy. RESULTS: Among 10 patients with SETs, EUS-FNA/B specimen results revealed a gastrointestinal stromal tumor in 4 patients and malignant lymphoma in 1 patient. The diagnostic accuracy of EUS-FNA/B was 50% for SETs (5/10). Among 20 patients with non-SET lesions, 8 patients were diagnosed with malignant disease and 7 were diagnosed with benign disease based on both EUS-FNA/B and the final results. The diagnostic accuracy of EUS-FNA/B for non-SET lesions was 75% (15/20). The size of lesions was the only factor related to diagnostic accuracy (P=0.027). Two complications of mild fever and asymptomatic pneumoperitoneum occurred after EUS-FNA/B. CONCLUSIONS: The overall diagnostic accuracy of EUS-FNA/B for rectal and perirectal lesions was 67% (20/30). EUS-FNA/B is a clinically useful method for cytological and histological diagnoses of rectal and perirectal lesions.
Biopsy* ; Biopsy, Fine-Needle ; Diagnosis ; Endoscopic Ultrasound-Guided Fine Needle Aspiration* ; Fever ; Gastrointestinal Stromal Tumors ; Gastrointestinal Tract ; Humans ; Lymphoma ; Needles ; Pneumoperitoneum ; Rectum

Direct peroral cholangioscopy (POC) which permits direct visualization of the biliary tree has recently gained widespread clinical use for diagnosis and treatment of various pancreatobiliary diseases. But, there is currently little reliable data on evaluating the complications of POC. POC is associated with complications such as pancreatitis, cholangitis, hemorrhage, rarely air embolism, and ductal perforation. The incidence of complication during POC is 2.9-12%. However, pneumoperitoneum due to intrahepatic bile duct perforation after POC has not yet been reported in Korea. We report a case of pneumoperitoneum after POC which has been successfully managed with endoscopic nasobiliary drainage and antibiotics.
Anti-Bacterial Agents ; Bile Ducts, Intrahepatic* ; Biliary Tract ; Cholangitis ; Diagnosis ; Drainage ; Embolism, Air ; Hemorrhage ; Incidence ; Korea ; Pancreatitis ; Pneumoperitoneum