Table of Content

15 September 2012, Volume 3 Issue 3

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Review Article

Novel insights for high mobility group box 1 protein-mediated cellular immune response in sepsis:A systemic review

Li-feng Huang, Yong-ming Yao, Zhi-yong Sheng

2012, 3(3):  165-171.  doi:10.5847/wjem.j.issn.1920-8642.2012.03.001

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BACKGROUND: High mobility group box 1 protein (HMGB1) is a highly conserved, ubiquitous protein in the nuclei and cytoplasm of nearly all cell types. HMGB1 is secreted into the extracellular milieu and acts as a proinflammatory cytokine. In this article we reviewed briefly the cellular immune response mediated by HMGB1 in inflammation and sepsis.

METHODS: This systemic review is mainly based on our own work and other related reports.

RESULTS: HMGB1 can actively affect the immune functions of many types of cells including T lymphocytes, regulatory T cells (Tregs), dendritic cells (DCs), macrophages, and natural killer cells (NK cells). Various cellular responses can be mediated by HMGB1 which binds to cell-surface receptors [e.g., the receptor for advanced glycation end products (RAGE), Toll-like receptor (TLR)2, and TLR4]. Anti-HMGB1 treatment, such as anti-HMGB1 polyclonal or monoclonal antibodies, inhibitors (e.g., ethyl pyruvate) and antagonists (e.g., A box), can protect against sepsis lethality and give a wider window for the treatment opportunity.

CONCLUSION: HMGB1 is an attractive target for the development of new therapeutic strategies in the treatment of patients with septic complications.

Original Articles

Could the number of CT angiograms be reduced in emergency department patients suspected of pulmonary embolism?

Zehtabchi Shahriar, Rinnert Stephan, Malhotra Shweta, Subramanian Arun, Timberger Mathew, Patel Brijal, Toro David, Hassan Khaled, Sinert Richard

2012, 3(3):  172-176.  doi:10.5847/wjem.j.issn.1920-8642.2012.03.002

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BACKGROUND: This study was undertaken to identify the prevalence of pulmonary embolism (PE) in the emergency department (ED) of an urban teaching hospital and also to test a Bayesian model in estimating the number of CT pulmonary angiography (CTA) expected to be performed in an emergency department.

METHODS: The data for this study was obtained through a retrospective review of electronic medical records for all ED patients suspected of PE who underwent chest CTA or ventilation perfusion scanning (V/Q) between 2009 and 2010. The data is presented as means and standard deviation for continuous variables and percentages with 95% confidence intervals (95%CI) for proportions. The prevalence of PE was used as pre-test probability in the Bayesian model. Post-test probability was obtained using a Fagan nomogram and likelihood ratios for CTA.

RESULTS: A total of 778 patients (560 females) with mean age of 50 years (range 18-98 years) were enrolled (98.3% underwent chest CTA and 1.7% underwent V/Q scan). A total of 69 patients had PE, rendering an overall prevalence of 8.9% (95%CI, 7.1% to 11.1%) for PE. We calculated that 132 CTA's per year could be avoided in our institution, without compromising safe exclusions of PE (keeping post-test probability of PE below 2%).

CONCLUSIONS: Despite differences in our patient populations and /or study designs, the prevalence of PE in our institution is about average compared to other institutions. Our proposed model for calculating redundant chest CTA is simple and can be used by institutions to identify overuse of CTA.

Impact of the United States propofol ban on emergency providers' procedural sedation agent choice and patient length of stay

Jonathan Pester, Joseph Robinson, John Prestosh, Suzanne Roozendaal, Rebecca Jeanmonod

2012, 3(3):  177-181.  doi:10.5847/wjem.j.issn.1920-8642.2012.03.003

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BACKGROUND: In the recent past, propofol was temporarily removed from the emergency department (ED) for use in procedural sedation. We sought to determine which agents replaced it in clinical practice and the impact this change had on turnaround times (TAT) for sedated patients.

METHODS: This study is a retrospective chart review at a level one trauma center. Patients receiving sedative agents (propofol, ketamine, midazolam, and etomidate) were identified by pharmacy codes, and their charts were then reviewed for demographics and TAT. Propofol was unavailable in the emergency department (ED) between May 2010 and February 2011. The study period extended from May 2009 until May 2011. Patients receiving sedation by non-emergency medicine physicians and those receiving sedation related to intubation were excluded.

RESULTS: In total 2466 charts were reviewed and 209 met inclusion criteria. When propofol was available, the most commonly used sedative agent was etomidate (40%), followed by propofol (28%), ketamine (20%), and midazolam (6%). When propofol was unavailable, etomidate remained the most commonly used agent (43%), followed by ketamine (41%), and midazolam (11%). When propofol was available, the median TAT for sedated patients was 163 minutes compared to 178 minutes when propofol was unavailable (P=0.83). When propofol was the primary sedative agent used, the median TAT was 166 minutes as compared with a median TAT of 172 minutes for all other sedative agents combined (P=0.87).

CONCLUSION: When propofol was unavailable, ketamine became a preferred ED sedation agent. Removal of propofol from the sedation armamentarium did not affect ED TAT.

Comparison of cosyntropin versus caffeine for post-dural puncture headaches: A randomized double-blind trial

Wesley Zeger, Bradley Younggren, Lynette Smith

2012, 3(3):  182-185.  doi:10.5847/wjem.j.issn.1920-8642.2012.03.004

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BACKGROUND: Cosyntropin has been reported to be effective in the treatment of post-dural puncture headaches, but there is a lack of data on its effectiveness. We compared the efficacy of cosyntropin with that of caffeine in the treatment of post-dural puncture headaches.

METHODS: We performed an interim analysis of a prospective, double blinded, trial of adult patients presenting to the emergency department with a post-dural puncture headache. Patients were randomized to receive either intravenous caffeine or intravenous cosyntropin. Values on a 100-mm visual analog scale (VAS) were recorded at 0, 60, and 120 minutes to assess pain. Rescue therapy was documented on the study data forms. Its effectiveness was determined by the need for this therapy.

RESULTS: Thirty-seven patients were included and four patients were excluded from the analysis because of protocol violations or incomplete data. Analysis was based on intention-to-treat. Caffeine was 80% (95% CI 60-100%) effective and cosyntropin was 56% (95% CI 33-79%) effective in treating post-dural puncture headaches. The group's VAS scores at 0, 60, and 120 minutes were 80 mm, 41 mm, 31 mm for caffeine and 80 mm, 40 mm, 33 mm for cosyntropin, respectively (P=0.66).

CONCLUSION: Caffeine was not more effective than cosyntropin in treating patients with post-dural puncture headaches, and there was no difference in the degree of pain relief on VAS assessment.

The relationship between serum levels of uric acid and prognosis of infection in critically ill patients

He-chen Zhu, Ruo-lan Cao

2012, 3(3):  186-190.  doi:10.5847/wjem.j.issn.1920-8642.2012.03.005

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BACKGROUND: Serum uric acid level is associated with some chronic diseases and prognosis of severe infection. This study aimed to investigate the relationship between serum uric acid (SUA) and prognosis of infection in critically ill patients.

METHODS: The data from 471 patients with infection admitted from January 2003 to April 2010 were analyzed retrospectively at Huashan Hospital Affiliated to Fudan University, Shanghai, China. The data of SUA, serum creatinine, blood urea nitrogen (BUN) and other relevant examinations within 24 hours after admission were recorded and the levels of SUA in those patients were described, then Student's t test was used to evaluate the relationship between SUA and pre-existing disorders. Different levels of SUA were graded for further analysis. The Chi-square test was used to examine the difference in the prognosis of infection.

RESULTS: The mean initial level of SUA within 24 hours after admission was 0.232±0.131 mmol/L and the median was 0.199 mmol/L. Remarkable variations in the initial levels of SUA were observed in patients with pre-existing hypertension (t=-3.084, P=0.002), diabetes mellitus (t=-2.487, P=0.013), cerebral infarction (t=-3.061, P=0.002), renal insufficiency (t=-4.547, P<0.001), central nervous system infection (t=5.096, P<0.001) and trauma (t=2.875, P=0.004). SUA was linearly correlated with serum creatinine and BUN (F=159.470 and 165.059, respectively, P<0.001). No statistical correlation was found between the initial levels of SUA and prognosis of infection (χ²=60.892, P=0.100).

CONCLUSION: The current study found no direct correlation between the initial levels of SUA after admission and prognosis of infection in critically ill patients.

Passive leg raising as an indicator of fluid responsiveness in patients with severe sepsis

Zhou-zhou Dong, Qiang Fang, Xia Zheng, Heng Shi

2012, 3(3):  191-196.  doi:10.5847/wjem.j.issn.1920-8642.2012.03.006

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BACKGROUND: In the management of critically ill patients, the assessment of volume responsiveness and the decision to administer a fluid bolus constitute a common dilemma for physicians. Static indices of cardiac preload are poor predictors of volume responsiveness. Passive leg raising (PLR) mimics an endogenous volume expansion (VE) that can be used to predict fluid responsiveness. This study was to assess the changes in stroke volume index (SVI) induced by PLR as an indicator of fluid responsiveness in mechanically ventilated patients with severe sepsis.

METHODS: This was a prospective study. Thirty-two mechanically ventilated patients with severe sepsis were admitted for VE in ICU of the First Affiliated Hospital, Zhejiang University School of Medicine and Ningbo Medical Treatment Center Lihuili Hospital from May 2010 to December 2011. Patients with non-sinus rhythm or arrhythmia, parturients, and amputation of the lower limbs were excluded. Measurements of SVI were obtained in a semi-recumbent position (baseline) and during PLR by the technique of pulse indicator continuous cardiac output (PiCCO) system prior to VE. Measurements were repeated after VE (500 mL 6% hydroxyethyl starch infusion within 30 minutes) to classify patients as either volume responders or non-responders based on their changes in stroke volume index (ΔSVI) over 15%. Heart rate (HR), systolic artery blood pressure (ABPs), diastolic artery blood pressure (ABPd), mean arterial blood pressure (ABPm), mean central venous pressure (CVPm) and cardiac index (CI) were compared between the two groups. The changes of ABPs, ABPm, CVPm, and SVI after PLR and VE were compared with the indices at the baseline. The ROC curve was drawn to evaluate the value of ΔSVI and the change of CVPm (ΔCVPm) in predicting volume responsiveness. SPSS 17.0 software was used for statistical analysis.

RESULTS: Among the 32 patients, 22 were responders and 10 were non-responders. After PLR among the responders, some hemodynamic variables (including ABPs, ABPd, ABPm and CVPm) were significantly elevated (101.2±17.6 vs.118.6±23.7, P=0.03; 52.8±10.7 vs. 64.8±10.7, P=0.006; 68.3±11.7 vs. 81.9±14.4, P=0.008; 6.8±3.2 vs. 11.9±4.0, P=0.001). After PLR, the area under curve (AUC) and the ROC curve of ΔSVI and ΔCVPm for predicting the responsiveness after VE were 0.882±0.061 (95%CI 0.759-1.000) and 0.805±0.079 (95%CI 0.650-0.959) when the cut-off levels of ΔSVI and ΔCVPm were 8.8% and 12.7%, the sensitivities were 72.7% and 72.7%, and the specificities were 80% and 80%.

CONCLUSION: Changes in ΔSVI and ΔCVPm induced by PLR are accurate indices for predicting fluid responsiveness in mechanically ventilated patients with severe sepsis.

Risk factors and outcomes of acute kidney injury after intracoronary stent implantation

Fei He, Jun Zhang, Zhong-qiu Lu, Qing-ling Gao, Du-juan Sha, Li-gang Pei, Guo-feng Fan

2012, 3(3):  197-201.  doi:10.5847/wjem.j.issn.1920-8642.2012.03.007

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BACKGROUND: Acute kidney injury following percutaneous coronary intervention (PCI) is associated with a worse outcome. However, the risk factors and outcomes of acute kidney injury (AKI) in patients after intracoronary stent implantation are still unknown.

METHODS: A retrospective case control study was done in 325 patients who underwent intracoronary stent implantation from January 2010 to March 2011 at the Drum Tower Hospital of Nanjing University School of Medicine. Those were excluded from the study if they had incomplete clinical data. The patients were divided into a normal group and a AKI group according to the standard of post-operation day 7 to identify AKI. The parameters of the patients included: 1) pre-operative ones: age, gender, hypertension, diabetes mellitus, cerebrovascular disease, left ventricular insufficiency, peripheral angiopathy, creatinine, urea nitrogen, estimated glomerular filtration rate (eGFR), hyperuricemia, proteinuria, emergency operation, hydration, medications (ACEI/ARBs, statins); 2) intraoperative ones: dose of contrast media, operative time, hypotension; and 3) postoperative one: hypotension. The parameters were analyzed with univariate analysis and multivariate logistical regression analysis.

RESULTS: Of the 325 patients, 51(15.7%) developed AKI. Hospital day and in-hospital mortality were increased significantly in the AKI-group. Univariate analysis showed that age, pre-operative parameters (left ventricular insufficiency, peripheral angiopathy, creatinine, urea nitrogen, estimated glomerular filtration rate, hyperuricemia, proteinuria, hydration), emergency operation, intraoperative parameters (operative time, hypotension) and postoperative hypotension were significantly different. However, multivariate logistic regression analysis revealed that increased age (OR=0.253, 95%CI=0.088-0.727), pre-operative proteinuria (OR=5.351, 95%CI=2.128-13.459), pre-operative left ventricular insufficiency (OR=8.704, 95%CI=3.170-23.898), eGFR≤60 ml/min/1.73 m² (OR=6.677, 95%CI=1.167-38.193), prolonged operative time, intraoperative hypotension (OR=25.245, 95%CI=1.001-1.034) were independent risk factors of AKI.

CONCLUSIONS: AKI is a common complication and associated with ominous outcome following intracoronary stent implantation. Increased age, pre-operative proteinuria, pre-operative left ventricular insufficiency, pre-operative low estimated glomerular filtration rate, prolonged operative time, intraoperative hypotension were the significant risk factors of AKI.

Risk factors and antibiotic resistance of pneumonia caused by multidrug resistant Acinetobacter baumannii in pediatric intensive care unit

Xiao-fang Cai, Ji-min Sun, Lian-sheng Bao, Wen-bin Li

2012, 3(3):  202-207.  doi:10.5847/wjem.j.issn.1920-8642.2012.03.008

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BACKGROUND: With beta-lactam drugs and immunosuppressants widely used, the infection caused by Acinetobacter baumannii (Ab) has become more and more serious with multidrug resistant Acinetobacter baumannii (MDRAb) emerging and worsening rapidly. Compared with other patients, the incidence and multidrug resistance of MDRAb are higher in children in pediatric intensive care unit (PICU) because of immune deficiency, severe basic diseases, prolonged hospitalization and invasive operations. Hence it is significant to study the epidemiology and changes of antibacterial susceptibility in order to reduce the incidence of MDRAb in children.

METHODS: A total 115 patients with MDRAb pneumonia and 45 patients with negative MDRAb (NMDRAb) pneumonia who had been treated from January 2009 to August 2011 were studied retrospectively at the PICU of Wuhan Children's Hospital. Clinical data were analyzed with univariate and multivariate Logistic regression.

RESULTS: In 176 clinical strains of Acinetobacter baumannii isolated, there were 128 strains of MDRAb, accounting for 72.73%. Drug susceptibility tests showed that the resistance rates of β-lactam antibiotics were more than 70% except for cefoperazone sulbactam. The rates to carbapenems were higher than 90%. They were significantly higher than those of NMDRAb. Amikacin, levofloxacin, ciprofloxacin and minocycline had the lowest drug-resistance rates (<20%). Multivariate Logistic regression revealed that ICU stay, the time of mechanical ventilation, anemia, hypoproteinemia and the use of carbapenems were independent risk factors for MDRAb pneumonia.

CONCLUSIONS: MDRAb is an important opportunistic pathogen to pneumonia in PICU, and its drug-resistance is severe. It increases significantly the mortality of patients. It is important to take the effective prevention measures for controlling it.

Comparison of extended spectrum β-lactamases-producing Escherichia coli with non-ESBLs-producing E.coli: drug-resistance and virulence

Sha Li, Yan Qu, Dan Hu, Yong-xin Shi

2012, 3(3):  208-212.  doi:10.5847/wjem.j.issn.1920-8642.2012.03.009

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BACKGROUND: The virulent factors of Escherichia coli (E.coli) play an important role in the process of pathopoiesis. The study aimed to compare drug-resistant genes and virulence genes between extended spectrum β-lactamases (ESBLs)-producing E.coli and non-ESBLs-producing E.coli to provide a reference for physicians in management of hospital infection.

METHODS: From October 2010 to August 2011, 96 drug-resistant strains of E.coli isolated were collected from the specimens in Qingdao Municipal Hospital, Qingdao, China. These bacteria strains were divided into a ESBLs-producing group and a non-ESBLs-producing group. Drug sensitivity tests were performed using the Kirby-Bauer (K-B) method. Disinfectant gene, qacEΔ1-sull and 8 virulence genes (CNF2, hlyA, eaeA, VT1, est, bfpA, elt, and CNF1) were tested by polymerase chain reaction (PCR).

RESULTS: Among the 96 E.coli isolates, the ESBLs-producing E.coli comprised 46 (47.9%) strains and the non-ESBLs-producing E.coli consisted of 50 (52.1%) strains. The detection rates of multiple drug-resistant strain, qacEΔ1-sull, CNF2, hlyA, eaeA,VT1, est, bfpA, elt, and CNF1 in 46 ESBLs-producing E.coli isolates were 89.1%, 76.1%, 6.5%, 69.6%, 69.6%, 89.1%, 10.9%, 26.1%, 8.7%, and 19.6%, respectively. In the non-ESBLs-producing E.coli strains, the positive rates of multiple drug-resistant strain, qacEΔ1-sull, CNF2, hlyA, eaeA, VT1, est, bfpA, elt, and CNF1 were 62.0%, 80.0%, 16.0%, 28.0%, 64.0%, 38.0%, 6.0%, 34.0%, 10.0%, and 24.0%, respectively. The difference in the detection rates of multiple drug-resistant strain, hlyA and VT1 between the ESBLs-producing E.coli strains and the non-ESBLs-producing E.coli strains was statistically significant (P<0.05).

CONCLUSION: The positive rate of multiple drug-resistant strains is higher in the ESBLs-producing strains than in the non-ESBLs-producing strains. The expression of some virulence genes hlyA and VT1 varies between the ESBLs-producing strains and the non-ESBLs-producing strains. Increased awareness of clinicians and enhanced testing by laboratories are required to reduce treatment failures and prevent the spread of multiple drug-resistant strains.

Protective effect of exogenous IGF-I on the intestinal mucosal barrier in rats with severe acute pancreatitis

Ying-zhen Wang, Shi-wen Wang, You-cheng Zhang, Zhi-jiang Sun

2012, 3(3):  213-220.  doi:10.5847/wjem.j.issn.1920-8642.2012.03.010

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BACKGROUND: Severe acute pancreatitis (SAP) can result in intestinal mucosal barrier (IMB) dysfunction. This study was undertaken to demonstrate the effect of IGF-I on the intestinal mucosal barrier in rats with SAP and its possible mechanisms.

METHODS: Seventy-two male Wistar rats were randomly divided into three groups: a sham operation (SO group, n=24), a SAP group not treated with IGF-I (SAP group, n=24), and a SAP group treated with IGF-I (IGF-I group, n=24). SAP was induced in the rats by injecting 5.0% sodium taurocholate into the biliary-pancreatic duct. The SO rats were given an infusion of normal saline instead. The rats in the IGF-I group underwent the SAP procedure and were given a subcutaneous injection of IGF-I at 30 minutes before the operation and at 3 hours after the operation. Eight rats in each group were sacrificed at 6, 12 and 24 hours after operation. Apoptosis of mucosal cells in the small intestine was determined by TUNEL. The levels of endotoxin and DAO and serum amylase were also measured. Pathologic changes in the small intestine were monitored. Changes of bax and bcl-2 mRNA expression in the small intestine were determined by reverse transcription polymerase chain reaction (RT-PCR).

RESULTS: The levels of serum amylase were lower in the IGF-I group than in the SAP group at all three time points (P<0.05). The levels of endotoxin in the IGF-I group were higher than those in the SAP group at 6 hours, but lower in the IGF-I group than in the SAP group at 12 and 24 hours (P<0.05). The levels of diamine oxidase were higher in the IGF-I group at 6 hours but lower than those in the SAP group at 12 and 24 hours. The pathological score of the small intestine was lower in the IGF-I group than in the SAP group, and the difference was statistically significant at 12 and 24 hours. The pathologic changes observed under electron microscopy were better in the IGF-I group than those in the SAP group. The apoptosis index of intestinal epithelial cells was significantly decreased in the IGF-I group compared with the SAP group. Compared with the SO group, the mRNA expression levels of bax were increased at each time point in the SAP group, and were significantly decreased in the IGF-I group as compared with the SAP group at each time point (P<0.05). The expression levels of bcl-2 were weak and not different between the SO group and the SAP group (P>0.05). They were significantly increased in the IGF-I group versus the SO and SAP groups (P<0.05). The ratio of bax and bcl-2 mRNA expression levels at each time point in the SAP group were significantly higher than those in the SO group, but they were obviously decreased in the IGF-I group.

CONCLUSIONS: Exogenous IGF-I seems to protect mucosal cells in the small intestine against SAP-induced apoptosis and could alleviate SAP-induced injury of the intestinal mucosa. The underlying mechanisms include enhanced mRNA expression of bcl-2 and inhibition of bax mRNA expression.

Undergraduate paramedic students cannot do drug calculations

Kathryn Eastwood, Malcolm J Boyle, Brett Williams

2012, 3(3):  221-226.  doi:10.5847/wjem.j.issn.1920-8642.2012.03.011

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BACKGROUND: Previous investigation of drug calculation skills of qualified paramedics has highlighted poor mathematical ability with no published studies having been undertaken on undergraduate paramedics. There are three major error classifications. Conceptual errors involve an inability to formulate an equation from information given, arithmetical errors involve an inability to operate a given equation, and finally computation errors are simple errors of addition, subtraction, division and multiplication. The objective of this study was to determine if undergraduate paramedics at a large Australia university could accurately perform common drug calculations and basic mathematical equations normally required in the workplace.

METHODS: A cross-sectional study methodology using a paper-based questionnaire was administered to undergraduate paramedic students to collect demographical data, student attitudes regarding their drug calculation performance, and answers to a series of basic mathematical and drug calculation questions. Ethics approval was granted.

RESULTS: The mean score of correct answers was 39.5% with one student scoring 100%, 3.3% of students (n=3) scoring greater than 90%, and 63% (n=58) scoring 50% or less, despite 62% (n=57) of the students stating they 'did not have any drug calculations issues'. On average those who completed a minimum of year 12 Specialist Maths achieved scores over 50%. Conceptual errors made up 48.5%, arithmetical 31.1% and computational 17.4%.

CONCLUSIONS: This study suggests undergraduate paramedics have deficiencies in performing accurate calculations, with conceptual errors indicating a fundamental lack of mathematical understanding. The results suggest an unacceptable level of mathematical competence to practice safely in the unpredictable prehospital environment.

Case Reports

Early diagnosis of bowel obstruction and strangulation by computed tomography in emergency department

Sohil Pothiawala, Apoorva Gogna

2012, 3(3):  227-231.  doi:10.5847/wjem.j.issn.1920-8642.2012.03.012

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BACKGROUND: Closed loop bowel obstruction is a specific type of mechanical obstruction with a high risk of strangulation and bowel infarction, especially in the small bowel. It is associated with a high mortality rate. Hence, it is important for emergency physicians to identify the presence of strangulation, while making the diagnosis of closed loop small bowel obstruction.

METHODS: We reported three patients with strangulated closed loop small bowel obstruction associated with severe abdominal pain, who had been treated at the emergency department. Urgent computerized tomography was performed in the patients.

RESULTS: Two patients were discharged with stable conditions, and one patient died after hemodialysis.

CONCLUSION: Urgent computerized tomography of the abdomen serves as an important diagnostic tool in view of its ability to detect the site, level and cause of obstruction along with the distinctive CT appearance of closed loop small bowel obstruction and signs of ischemia. Early definitive diagnosis will guide subsequent management and improve outcomes.

Acute abdomen caused by nontraumatic hemoperitoneum is the first manifestation of gastric low grade stromal tumor

Savas Yakan, Enver Ilhan, Fevzi Cengız, Hülya Mollamehmetoglu, Kemal Emre Telciler

2012, 3(3):  232-234.  doi:10.5847/wjem.j.issn.1920-8642.2012.03.013

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BACKGROUND: Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract in adults. We treated surgically a man with acute abdomen caused by non-traumatic hemoperitoneum and diagnosed by low grade gastric GIST.

METHODS: A 51-year-old Caucasian man came to the hospital for abdominal pain for 3 hours. He had no history of abdominal trauma. On admission, he was conscious and alert, and he had hypotension (80/50 mmHg) and moderate tachycardia. Abdominal ultrasonography showed the presence of free peritoneal fluid. Abdominal magnetic resonance imaging (MRI) showed diffuse intraabdominal hemorrhage and solid mass lesion at the greater curvature of the stomach. At an emergency laparotomy, a pedunculated, fragile mass of 5x6 cm originating from the posterior wall of the stomach was seen. The tumor was resected. Histopathologically a gastrointestinal stromal tumor was detected.

RESULTS: The patient had an uneventful postoperative course and was discharged on the sixth postoperative day. Follow-up showed no recurrence of the tumor 8 months after surgery.

CONCLUSION: Intraabdominal bleeding is a rare presentation of gastrointestinal stromal tumors. The diagnosis of the tumor should be based on whether sudden abdominal pain occurs in patients with an intraabdominal mass.

Images in emergency medicine: giant ascending aortic aneurysm dissection with hemopericardium

Boon Ong, Martyn Harvey, Grant Cave

2012, 3(3):  235-236.  doi:10.5847/wjem.j.issn.1920-8642.2012.03.014

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BACKGROUND: Acute chest pain represents a common presentation at emergency department. Aortic dissection in young patients, however, is fortunately rare.

METHODS: We report a case of giant ascending aortic aneurysm with Stanford type A aortic dissection in an otherwise well 22-year-old male patient. Operative aortic valve and root replacement was undertaken with favourable outcome.

RESULTS: Histopathologic examination of the resected aorta revealed acute on chronic inflammatory change with Langerhans type giant cells consistent with a diagnosis of giant cell aortitis.

CONCLUSION: While uncommon, emergencies of the aorta may present in young patients. Predisposing conditions are discussed.