1/4. Lethal gastric rupture caused by acute gastric ulcer in a 6-year-old girl.Gastric rupture is extremely rare in childhood beyond the neonatal period. We describe a previously healthy 6-year-old girl with a large laceration along the greater curvature on the posterior wall of the stomach. The patient was admitted to a neighboring hospital because of vertigo with 1-day history of intractable vomiting and epigastric pain. Although abdominal distension was noticed during the physical examination, muscular rigidity was not detected on palpation. Laboratory data showed severe hypotonic dehydration and moderate metabolic acidosis with hyperkalemia. She suddenly developed cardiac arrest within an hour after admission. After resuscitation, surgical consultation was obtained. Abdominal X-ray and ultrasound revealed abdominal free air and massive cloudy ascites. At laparotomy, there was a large laceration on the greater curvature of the stomach. pathology of the gastric wall showed mucosal necrosis while the musculature remained intact consistent with an acute gastric ulcer. Since clinical condition of gastric rupture deteriorates rapidly, early diagnosis and appropriate treatment is essential for good prognosis. One should consider that ulcer formation might cause gastric rupture in childhood.- - - - - - - - - - ranking = 1keywords = physical examination, physical (Clic here for more details about this article) |
2/4. Multiple gastrointestinal stromal tumors and synchronous ileal carcinoids.BACKGROUND: A 74-year-old African-American male presented with a 3-day history of hematemesis and melena. The patient reported no abdominal pain, constitutional symptoms, bright red blood per rectum, constipation, or diarrhea. His physical examination and medical history were unremarkable except for benign prostatic hypertrophy. An esophagogastroduodenoscopy showed a 3 x 2 x 2 cm smooth round mass in the cardia, 2 cm distal to the gastroesophageal junction. biopsy of the mass revealed an ulcerated tumor composed of spindle cells. immunohistochemistry showed positive staining for a number of biochemical markers, including KIT, Ki-67 and smooth muscle actin, but was negative for the markers S100 and desmin. A gastric-wedge resection revealed an ulcerated 4.5 cm mass in the stomach, and exploration of the abdomen revealed two ileal carcinoid tumors, jejunal diverticula and reactive mesenteric lymphadenopathy. INVESTIGATIONS: Esophagogastroduodenoscopy, biopsy, CT scan, immunohistochemistry, dna microarray analysis and quantitative reverse transcriptase-PCR. DIAGNOSIS: Multiple gastrointestinal stromal tumors occurring concomitantly with ileal carcinoids. MANAGEMENT: Gastric-wedge resection and segmental resection.- - - - - - - - - - ranking = 1keywords = physical examination, physical (Clic here for more details about this article) |
3/4. Perforated peptic ulcer in the elderly.From 1973 through 1979, 32 patients over 60 years of age were admitted to the Beth israel Medical Center, new york, because of a perforated gastric or duodenal ulcer. In many of them, the symptoms and physical findings were minimal. In abdominal roentgenograms (subject erect or supine), only 17 (60 percent) of these patients showed free intraperitoneal air. Among the 29 surgically treated patients, plication of the ulcer was performed in 28 and hemigastrectomy-vagotomy in one. The postoperative morbidity rate was 62 percent, and the mortality rate 17 percent. In 3 of the 32 patients, the diagnosis of perforated ulcer was established only at autopsy. Thus, failure to diagnose this condition accurately may be the principal cause of death in elderly patients with a perforated peptic ulcer. The increased use is recommended of contrast roentgenograms of the stomach and duodenum and of endoscopy, in an effort to improve diagnostic accuracy in dealing with perforated peptic ulcers.- - - - - - - - - - ranking = 0.064952283194324keywords = physical (Clic here for more details about this article) |
4/4. From emergency room to morgue: deaths due to undiagnosed perforated peptic ulcers. Report of four cases with review of the literature.peptic ulcer perforation is well recognized as a cause of peritonitis and can result in death. Although amenable to surgery, delay in making the correct diagnosis results in increased mortality. Accurate diagnosis has been hindered by demographic changes in the affected population. In recent years, the population at risk has increased. Specifically, a rising incidence has been observed in women, in the elderly, and in patients with previously undiagnosed peptic ulcer disease. Described are four patients with perforated peptic ulcers, three of which were not detected prior to autopsy. In three of the four instances the patient had been observed in and discharged from a hospital emergency room during the 30 h prior to death. In the fourth case, the decedent had been seen in and discharged from the emergency room four times during the month prior to death. In all patients, the presenting historical, physical, and/or radiographic findings were indicative of perforation. The death of a patient within days of a visit to an emergency room should prompt a forensic autopsy. The role of medical examiners in providing quality assurance feedback to emergency rooms located within their jurisdiction is emphasized.- - - - - - - - - - ranking = 0.064952283194324keywords = physical (Clic here for more details about this article) |