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1/9. Gastric perforation due to the ingestion of a hollow toothpick: report of a case.

    A perforation due to the ingestion of a toothpick is a condition seldom seen in the stomach. We herein describe an 80-year-old woman with a perforation of the stomach due to an ingested hollow toothpick. The toothpick was easily removed during a mini-laparotomy. The site of perforation was closed with absorbable sutures and omentum was used to function as an overlying patch. The postoperative course was uncomplicated. The hollow toothpick functioned as a fistula between the contents of the stomach and the peritoneal cavity. This resulted in a very different clinical picture from that observed in "classical wooden" toothpick injury, where the toothpick is not able to function as a fistula. To the best of our knowledge, this is the first description of a hollow toothpick perforating the stomach. A hollow toothpick perforation must be considered in any patient with symptoms of intestinal perforation, even when there is no history of swallowing toothpicks. Removal of a toothpick and subsequent suturing of the puncture site is a simple and relatively minor surgical procedure, which may have a lower morbidity and mortality as compared to other causes of gastric perforation. A precaution to observe, is the potential danger that one of the members of the operating team might perforate a finger.
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2/9. A penny for your thoughts: small bowel obstruction secondary to coin ingestion.

    We report a case of small bowel obstruction secondary to coin ingestion. A 22-year-old woman presented to the Emergency Department (ED) with a 3-week history of abdominal pain. Upon initial history the patient denied any foreign body ingestion. Only after computed tomography (CT) scanning of the abdomen and pelvis did the patient admit to deliberate ingestion of a single united states penny coin. During surgical evaluation it was found that the coin had lodged near the ileocecal valve and an inflammatory mass had formed around the intraluminal coin, causing a 10 x 7 cm fibrous tumor to completely obstruct the small bowel. It is thought that oxidation of the coin, with subsequent exposure of its high zinc content, instigated the inflammatory cascade.
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3/9. A case of group B streptococcal pyomyositis.

    The group B streptococcus is an opportunistic pathogen that causes a variety of serious infections including bacteremias, puerperal sepsis, and neonatal meningitis. Group B streptococcal infections of muscle are rare. We report here an unusual case of group B streptococcal pyomyositis. pyomyositis arises predominantly from infections caused by staphylococcus aureus and, occasionally, streptococcus pyogenes. Because of the rarity of pyomyositis in temperate climates, the common lack of localizing signs or symptoms, and the frequently negative blood cultures, considerable delay often precedes the diagnosis of pyomyositis; in fact, the infection has been initially misdiagnosed as muscle hematoma, cellulitis, thrombophlebitis, osteomyelitis, or neoplasm. diagnosis may be greatly aided by radiologic techniques that can demonstrate the sites of muscle enlargement and the presence of fluid collections. The response to antibiotics is usually rapid, but resolution of the infection may require aspiration of deeply situated muscle abscesses. This report describes a diabetic patient with an unusual presentation of pyomyositis that mimicked an acute abdomen.
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keywords = aspiration
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4/9. death, after swallowing and aspiration of a high number of foreign bodies, in a schizophrenic woman.

    A 46-year-old woman who had had a long-term schizoid psychosis collapsed on the street. Upon admission to the hospital, she was determined to have an acute abdomen. The chest radiograph showed metallic foreign bodies in both main bronchi; foreign bodies in the stomach were not observed clinically. The woman died from repeated cardiac arrest shortly after hospital admission. At the autopsy a screw and a nail were found in both main bronchi. The abdominal cavity contained 2 L of greenish purulent fluid and a massive fibrinoid peritonitis was observed. Two perforations of the stomach, each 1 cm in diameter, were detected. The stomach was completely filled with a mass of metallic foreign bodies, greenish fluid, and a bezoar of a total weight of 1,400 g; 422 distinguishable and mostly metallic foreign bodies were counted. death was attributed to cardiac arrest in delayed shock after massive purulent peritonitis caused by two gastric perforations combined with obstruction of the airways by aspirated foreign bodies. Cases of massive swallowing of foreign bodies are mainly restricted to mentally handicapped persons, especially schizophrenics, whereas acute impaction of the larynx by large food particles occurs nearly exclusively in heavily intoxicated adults.
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5/9. Tension pneumoperitoneum.

    A 26-year-old woman developed the adult respiratory distress syndrome after a post-partum haemorrhage. After mechanical ventilation was started the signs of a tense and distended acute abdomen developed. The aspiration and subsequent analysis of copious intra-peritoneal gas confirmed the diagnosis of a tension pneumoperitoneum secondary to pulmonary barotrauma.
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6/9. A bronchopleurocutaneous fistula caused by an unusual foreign body aspiration simulating acute abdomen.

    A 12-year-old boy was admitted to hospital for abdominal pain, vomiting and fever. On physical examination he had rales on the lower right hemithorax without any respiratory complaints. Chest X-ray revealed a condensation in the right lower chest. Abdominal findings were secondary to lobar pneumonia. Treatment of pneumonia with antibiotics showed no improvement over 2 days. On bronchoscopy no foreign body was seen, but pus was aspirated. Two days later a mass appeared on the right hemithorax and fistulized. An organic foreign body, hordeum murinum, with 3-5 ml of pus was observed. Chest X-ray taken at the day of fistulization showed no pneumothorax or subcutaneous emphysema. Less than 11 cases of pneumocutaneous fistulas secondary to aspiration of grasses have been reported in literature. Why an ear of hordeum murinum can migrate only in a forward direction and why a pneumothorax had not developed is discussed.
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7/9. Acute abdomen following dermoid cyst rupture during transvaginal ultrasonographically guided retrieval of oocytes.

    We report a case of acute abdomen due to puncture of a dermoid cyst during oocyte aspiration, which required laparotomy. A woman who had undergone an in-vitro fertilization and embryo transfer required hospitalization due to onset of an acute abdomen. An ultrasonographic scan showed a pelvic mass with the features of dermoid cyst. The patient required diagnostic laparotomy which confirmed the presence of a ruptured dermoid cyst with subsequent peritonitis.
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8/9. Necrotizing myofasciitis: an atypical cause of "acute abdomen" in an immunocompromised child.

    We report the case of an immunocompromised 15-year-old boy who presented with symptoms mimicking an "acute abdomen" related to necrotizing myofasciitis of the anterior abdominal wall. CT demonstrated the abdominal wall process as the cause of the patient's symptoms and sonographically guided aspiration confirmed the diagnosis. Despite prompt diagnosis and aggressive surgical debridement, the infection continued to progress and the patient died within 24 h of presentation.
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9/9. Gastric necrosis after fundoplication: a novel approach for esophageal preservation.

    An 11-year-old boy presented moribund, with massive abdominal distension. A Nissen fundoplication and gastrostomy tube had been established at age 2 years. After attempts to pass a nasogastric tube were unsuccessful, the old gastrostomy site was used to gain percutaneous access to the stomach resulting in release of gastric contents and stabilization of blood pressure and perfusion. During operation, massive gastric distention with gastric necrosis was found. Subtotal gastrectomy was performed with stapled closure of the distal intraabdominal esophagus and prepyloric region. Sump suction was placed in the proximal esophagus and the abdomen was drained widely. A distal esophageal perforation was apparent on postoperative day 19 confirmed by imaging and endoscopy. A nasoesophageal tube was passed into the abdomen, tied to a Jackson-Pratt drain, and the composite tube repositioned in the midesophagus allowing controlled proximal and distal drainage. Six months later, a Hunt-Laurence esophagojejunal pouch was created. At age 13, the child is clinically well, and enjoys 50% of his nutritional needs orally, with the remainder delivered overnight via tube feedings. This case describes gastric necrosis after gas bloat syndrome as a late complication of Nissen fundoplication. A novel approach to the management of distal esophageal perforation allowed preservation of a functional, intact native esophagus.
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keywords = gastric content, content
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