bluuebunny/crossref_metadata_2025_split huggingface dataset:
794 Diagnostic Pitfall in Atypical Presentation of Malignant Gastric Ulcer Perforation
Authors: Oo M K , Tun T N , Aung M 
Published: October 2021

Abstract

Background
Peptic ulcer perforation is one of the most common surgical problems in daily practice. Although it can be easily diagnosed clinically, the clinical presentation can be less obvious in some cases leading to diagnostic pitfalls and mortality. This case report aims to highlight an atypical presentation of malignant gastric ulcer perforation in a patient with chronic abdominal pain.

Case presentation
A 78-year-old lady presented with chronic abdominal pain for 3 months. Investigations and imaging revealed T2N1M0 malignant gastric ulcer which was confirmed by endoscopy. Due to her low body mass index and underlying comorbidities, she was admitted for pre-operative optimization. However, she was a good 78 with the clinical frailty scale 4 and the National Early Warning Score 0 throughout the stay. On the night before the operation, she suddenly developed delirium. Further history revealed marked oliguria for 12 hours. There was mild abdominal distension without peritonism. She was catheterized and treated with fluids and antibiotics. X-ray suggested massive pneumoperitonium. Subsequently, she developed full-blown septic shock with rapid clinical deterioration within 3 hours. With the estimated Boey scoring of 3 and rapid clinical deterioration, the symptom control approach was decided. A palliative bedside ascitic tap was performed to relieve the discomfort. Four hours after the onset, unfortunately, the patient passed away.

Conclusions
Although gastric ulcer perforation usually presents with obvious symptoms, extra precaution should be exercised in elderly patients with chronic abdominal pain and comorbidities. We could learn that routine monitoring of urine output might aid in the early diagnosis of sepsis.
830 A Case of Colo-Colonic Intussusception Secondary to A Large Lipoma in An Adult
Authors: Koronfel M , Jamal A , Edmonds R 
Published: October 2021

Abstract
Colonic lipomas are benign tumours, most commonly in the right colon or caecum, usually detected incidentally at colonoscopy and are often asymptomatic not requiring treatment. Lipomas leading to intussusception have previously been described in case reports, but it remains a rare occurrence, no specific incidence data has been documented. We present the case of a patient with a 7cm colonic lipoma that developed an intussusception.
This patient suffered non-specific pulling pain along the right and upper abdomen for many years. A distal ascending colonic lipoma was identified, on repeated imaging and colonoscopy and biopsied. It was concluded that the abdominal pain was due to gallstones, diverticulitis and adhesions from previous pelvic surgery. In early December 2020, the patient was reviewed and listed for elective cholecystectomy. Later the same month, the patient was admitted with severe abdominal pain, watery and bloody diarrhoea. CT scan showed the colonic lipoma had acted as the lead point for an intussusception, with the lipoma and surrounding colon having intussuscepted into the transverse colon. Patient had an open right hemicolectomy and anastomosis for colo-colic intussusception secondary to the lipoma. Subsequently, the patient developed anastomotic breakdown requiring relook laparotomy with resection of ileo-colic anastomosis and end ileostomy formation.
Adults presenting with intussusception is rare and associated with nonspecific signs and symptoms. Variability in clinical presentation highlights the need for a low index of suspicion in people with known colonic masses. In addition, early surgical intervention should be considered in masses &gt;4cm as previously suggested in the literature.
952 When A Surgeon Was Called to The Obstetric Unit: A Rare Case of Gonococcal Peritonitis in A 12-Week Pregnancy
Authors: Ann Jacob P , Jacob L 
Published: October 2021

Abstract

Background
Primary bacterial peritonitis presenting as septic shock is infrequently seen in clinical practice. This is a case of gonococcal peritonitis presenting as septic shock in a pregnant lady needing emergency laparotomy, drainage of purulent fluid and abdominal lavage.

Case Presentation
A 35-year-old woman presented with severe generalised abdominal pain. No history of fever, vomiting, urinary or bowel complaints. She was in her 4th pregnancy, at 12-weeks gestation. She was afebrile but tachycardic and hypotensive. Abdomen was tender and there was no vaginal bleeding. Ultrasound scan showed minimal fluid in hepatorenal area and a viable intrauterine pregnancy. Differential diagnosis were ruptured appendix, ectopic pregnancy, acute abdomen and shock. Exploratory laparotomy was done. Moderate amount of purulent fluid was noted within the abdominal cavity and no bleeding was seen. General surgeon was called for assistance by the Obstetrician as no foci of infection was found. The uterus, fallopian tubes, ovaries, appendix, bowel and upper abdominal organs were found to be intact. Peritoneal fluid culture was taken. Drainage of purulent fluid and peritoneal wash was done. She was nursed in ICU because of peritonitis with septic shock and AKI. Peritoneal fluid culture showed Neisseria gonorrhoea and IV ceftriaxone was given for 7 days. Postoperatively she recovered well but needed evacuation of uterus for a missed miscarriage. She was screened for other STIs and were negative.

Discussion
Gonorrhoea is the second most common reported STI. It can present as acute peritonitis when the infection has spread beyond upper reproductive tract organs.
956 Retained Appendiceal Tip and Abdominal Wall Appendicolith - A Rare Combination of Post Appendicectomy Complications
Authors: Dey A , Symons N 
Published: October 2021

Abstract
Appendicitis involving the appendix stump is a recognised post appendicectomy complication but the same involving the appendiceal tip is rare. Similarly, abdominal wall abscess secondary to retained appendicolith is also infrequently encountered. Our case highlights a rare combination of both complications arising separately.
A 29-year-old man presented with 3 days of generalised malaise and progressively worsening right iliac fossa pain some ten months after a laparoscopic appendicectomy. This had been complicated by residual right iliac fossa inflammation that was treated conservatively and serial scans demonstrated gradually resolving inflammation. He also had well controlled ulcerative colitis.
On examination, he was noted to be pyrexial with a tender fluctuant mass in the right flank. An ultrasound scan demonstrated inflammatory changes in the abdominal wall with no intra-abdominal collections. A diagnostic laparoscopy found an inflamed appendix tip, attached to the residual mesoappendix and embedded in the abdominal wall behind the mid-ascending colon. A completion appendicectomy was performed.
The patient recovered well but returned 4 months later with persistent pain and a fluctuant mass over the right iliac fossa. Radiological investigation revealed an abdominal wall collection containing a calcified appendicolith. The collection was refractory to ultrasound guided drainage and an exploration of the abdominal wall allowed extraction of the appendicolith followed by symptomatic relief.
This case emphasizes the importance of complete excision of the appendix and extraction of debris, which can be challenging when the appendix lies in a retro-colic position.
983 Digital Angioleiomyoma: A Rare Tumour Of the Hand
Authors: Motiwala F , Jivan S 
Published: October 2021

Abstract

Introduction
Angioleiomyoma is an unusual, benign tumour originating from the tunica media of blood vessels. They commonly occur in the face, neck and lower limb. It is rarely found in the hand and is not considered in the differential diagnoses of painful subcutaneous hand tumours.

Case Report
We present a case of a 40-year-old man with a several month history of a slow growing lump on his right middle finger. He complained of pain and difficulty flexing his finger. On examination, he had a solid tumour with normal overlying skin, on the volar ulnar border of middle phalanx with altered sensation and a positive Tinel’s along the ulnar digital nerve. Ultrasound and MRI reported a highly vascular subcutaneous tumour measuring 26x14x22mm with differential diagnoses of giant cell or peripheral nerve tumour. Intra-operatively the tumour was in continuity with the ulnar digital artery and solid in consistency. Tumour excision and microsurgical repair of the digital artery was required. Histology confirmed a well-defined nodule, composed of bundles of smooth muscle surrounding ectatic blood vessels, consistent with angioleiomyoma. On follow-up the patient reported return of full range of movement without hypersensitivity or evidence of recurrence.

Conclusions
Angioleiomyomas in the hand are rare. It should be considered in the differential diagnoses of painful subcutaneous tumours. Ultrasound and MRI are non-specific. Treatment is successful with excision biopsy and microsurgical repair of digital artery. Microvascular instruments should be available, and the patient consented for vein graft.
1067 Neoplasia in Association with a Congenital Anomaly: Wilms Tumor in a Horseshoe Kidney
Authors: Mubarak M , Alhamdan O , Alaradi H , Alhindi S 
Published: October 2021

Abstract

Introduction
Horseshoe malformation is the most common form of fusion defects involving the kidney, whereas Wilm's tumor is the most common primary malignant renal tumor in children. The co-incidence of these two pathologies gives off an incidence rate of 0.48%.

Case Report
This is a case of a two-year-old female who presented early in life with multiple congenital anomalies including congenital heart disease, bilateral aniridia, persistent thrombocytopenia, and sickle cell trait in association with a painless abdominal mass. A CT scan showed a horseshoe kidney. The patient was lost for follow up until the age of two years, in which another CT scan revealed a left lower pole focal cystic mass measuring 5.1x5.3x6.3cm. WAGR syndrome was suspected and confirmed through genetic testing. A multidisciplinary approach was necessary to manage her efficiently due to the numerous co-existing congenital pathologies. The patient underwent six cycles of chemotherapy leading to a 35% reduction in tumor size and a left nephrectomy. She was admitted to the pediatric ICU post-operatively for observation. Histopathological analysis revealed features of stage two stromal type nephroblastoma. Her renal function and urine output were satisfactory throughout the duration of her admission as well as on follow up.

Conclusions
Keeping a high index of suspicion is imperative; individuals with renal anomalies, namely horseshoe kidney in the context of WAGR syndrome, mandate a comprehensive assessment through clinical examination, laboratory workup, and imaging. Though different approaches to standard Wilm's tumor cases have been explored thoroughly, it is crucial to keep in mind the need for multidisciplinary involvement in patients with multiple congenital anomalies.
1094 Diagnosis of Diabetic Ketoacidosis Delayed Due to Concomitant Acute-On-Chronic Pancreatitis
Authors: Lung N 
Published: October 2021

Abstract
The objective of this clinical case is to highlight the importance of recognition and prompt management of diabetic ketoacidosis (DKA) in older patients with comorbidities such as acute pancreatitis.
A 61-year-old gentleman initially presented to the hospital with severe left upper quadrant/epigastric pain and vomiting. He had a background of chronic pancreatitis, diabetes secondary to pancreatitis and alcohol excess. Based on his raised inflammatory markers and CT findings which showed pancreatic pseudocyst compressing on the spleen, a diagnosis of acute-on-chronic pancreatitis and possible intra-abdominal sepsis was made. He was subsequently commenced on piperacillin with tazobactam and given fluids.
His abdominal pain persisted despite initial treatment. His blood glucose levels were within normal range, but his ketone levels were found to be consistently high since admission. Two days later, he presented with reduced consciousness and generalised abdominal tenderness; his arterial blood gas showed a very severe metabolic acidosis. A diagnosis of DKA was then made – he was commenced on the DKA treatment protocol and was transferred to the Intensive Care Unit for stabilisation. He gradually made a recovery and was later transferred from the ICU to the endocrinology ward.
DKA usually presents in younger patients with type 1 diabetes. Given the background of this patient, his presentation was largely attributed to a surgical cause. Clinicians must remain alert to the possibility of dual diagnoses relating to abdominal pain, which in this case were a surgical cause (pancreatitis) and a medical cause (DKA).
1150 A Painless Anterior Chest Wall Mass Post Coronary Artery Bypass Grafting Surgery
Authors: Reid R , Alakhras Aljanadi F , Beattie R , Graham A 
Published: October 2021

Abstract

Aim
We aim to present here a case of a painless anterior chest wall mass which was first noted during routine follow up post coronary artery bypass graft surgery

Case presentation
An 80-year-old male developed an asymptomatic slow growing pronounced swelling over the right anterior chest wall post CABG. His other past medical history includes chronic obstructive pulmonary disease, pulmonary fibrosis, ischaemic heart disease, an AICD for complete heart block, hypertension, hyperlipidaemia and osteoarthritis. A CT scan demonstrated a 10 x 12 x 6.5 cm subcutaneous lesion at the mid-line of the lower chest wall adjacent to the xiphisternum and the previous sternotomy site. On clinical examination there was a large non-tender cystic swelling with peripheral calcifications, but overlying skin was normal. Fluid was aspirated from the lesion and cytology showed a paucicellular specimen with features in keeping with seroma. Due to the progressive increase in size patient underwent surgical resection. A gelatinous bloody fluid was aspirated from the lesion and it was then resected enbloc. The tumour base appeared to arise from 6/7th costal cartilage and tumour was shaved away. The mass was confirmed histologically to be chondrosarcoma.

Conclusions
Given the uncommon prevalence of malignant primary chest wall tumours this case highlights the importance of high clinical suspicion even after developing post CABG.
1399 Anorectal Melanoma: Can Be an Unexpected Diagnosis - A Case Report
Authors: Hagiga A , Shaaban M , Gultiaeva M 
Published: October 2021

Abstract
Anorectal melanoma is a rare tumour. Few cases are reported in the literature. We report a case of 51 years old male complained of anal induration, itching and bloody and suppurative discharge. Patient had symptoms for 2 years. However, patient expected his symptoms are due to recurrence of haemorrhoids. Therefore, he presented late. Then, he had noticed a progressive increase in size, discharge and two opposing ulcers. Patient had no history of abdominal pain, change in bowel habits, bleeding per rectum, history of groin lumps, incontinence nor erectile dysfunction. Patient underwent haemorrhoidectomy about 11 years ago. On examination, there was a circumferential single ulcer eroding the anus extending deep to the dentate line reaching the rectum on digital rectal examination. Also, there was no inguinal lymphadenopathy detected on exam. Incisional biopsy of the ulcer showed anorectal melanoma. Patient had abdominoperineal resection (APR) with adjuvant radiotherapy. At 12 months follow up, there were no signs of recurrence.
1590 Reconstructing Periorbital Necrotising Fasciitis - A Case Report
Authors: Li Z , Filobbos G 
Published: October 2021

Abstract
Periorbital necrotising fasciitis is a rare life-threatening presentation. We present a case of an 87-year-old patient with periorbital necrotising fasciitis. The patient was successfully managed by prompt diagnosis, debridement and reconstruction with a thick split thickness skin graft harvested from the scalp. To the best of our knowledge, this is the first case report in literature suggesting the use of sheet skin grafts from the scalp in reconstruction of necrotising fasciitis. The patient was discharged after 20 days and has no residual corneal or scleral show despite losing bilateral upper and lower eyelid skin. We present the case with photographs of initial presentation, debridement, and final reconstruction.
Reconstruction of post-debridement necrotising fasciitis offers a challenge to the plastic surgeon. The wound bed is not ideal and commonly colonised. We suggest the use of thick split thickness skin grafts harvested from the scalp. Despite their utility in burns surgery, the use of scalp split thickness skin is not documented in literature for reconstruction of necrotising fasciitis. We believe this type of skin graft offers multiple advantages: higher rate of graft takes, less contracture and inconspicuous donor site morbidity. Time to reconstruction is particularly important in patients with eye lid skin loss and we believe this type of skin graft offers a versatile solution when graft take is essential.
1678 A Rare Example of a Simple Bone Cyst of The Ascending Ramus in A Paediatric Patient
Authors: Aruede G , Carey E , Bhatia K , Smart K 
Published: October 2021

Abstract
A simple bone cyst is described as an intra-osseous pseudocyst, devoid of an epithelial lining and either empty of filled with serous or sanguineous fluid. This case presents a rare example of a simple bone cyst of the ascending ramus of the mandible in a paediatric patient. Studies have shown that less than 5% of simple bone cysts of the jaw bones are located within the mandibular ramus, with the most common site being the premolar-molar region (75%). The 14-year-old female was referred by her orthodontist to the local Oral and Maxillofacial department, for an incidental finding on her pre-orthodontic OPT of a radiolucency in the left ascending ramus. Her medical history was clear, she was asymptomatic and had no sensory deficit. A CT scan demonstrated a 22mm multilocular radiolucency centred on the left ascending ramus, extending superiorly up to the base of the coronoid process and condylar neck. Inferiorly, the radiolucency abutted but did not involve the unerupted third molar. The scan highlighted thinning of the buccal and lingual cortices putting the patient at risk of pathological fracture. The inferior alveolar nerve canal passed through the lingual aspect of the radiolucency. The patient underwent exploration of the left mandible which revealed an empty bony cavity, with no cystic lining or contents. The definitive diagnosis of a simple bone cyst was established. She experienced satisfactory healing by her review appointment 4 weeks post-surgery. Combined radiographic and clinical assessment is important in the diagnosis of simple bone cysts.
663 A Multi-centre National Study of the Effectiveness of Virtual Fracture Clinic Management of Orthopaedic Trauma during the COVID-19 Pandemic (MAVCOV): A Cross-sectional Study Protocol
Authors: Ng Z H , Downie S , Makaram N , Kolhe S , Mackenzie S , Clement N , Duckworth A , White T 
Published: October 2021

Abstract

Aim
Virtual fracture clinics (VFCs) are advocated by recent British Orthopaedic Association Standards for Trauma and Orthopaedics (BOASTs) to efficiently manage injuries during the COVID-19 pandemic. The primary aim of this national study is to assess the impact of these standards on patient satisfaction and clinical outcome amid the pandemic. The secondary aims are to determine the impact of the pandemic on demographics of injuries presenting to the VFC and to compare outcomes and satisfaction when the BOAST guidelines were first introduced with a subsequent period when local practice would be familiar with these guidelines.

Method
This is a national cross-sectional cohort study comprising centres with VFC services across the United Kingdom. All consecutive adult patients assessed at VFC pre-lockdown (6 May 2019 to 19 May 2019) and at the peak of the first lockdown (4 May 2020 to 17 May 2020), and a randomly selected sample during the second wave (October 2020) will be eligible for the study. Data comprising local VFC practice, patient and injury characteristics, unplanned re-attendances, and complications will be collected. A telephone questionnaire will be used to determine patient satisfaction and patient-reported outcomes for patients who were discharged following VFC assessment without face-to-face consultation.

Results
As of 31 October 2020, 51 hospitals with VFC services have been recruited to participate in this study.

Conclusions
The study results will identify changes in case-mix and numbers of patients managed through VFCs, due to urgent necessity, and whether this is safe and is associated with patient satisfaction to inform future clinical practice.
1277 A Closed-Loop Audit of the use of qFIT in Symptomatic “Two Week Wait” referrals in Somerset Foundation Trust
Authors: Cullen J , Chambers A , Smyth E , Mackey P l , Hunt L , Bamford R 
Published: October 2021

Abstract

Introduction
Quantitative faecal immunochemical test (qFIT) is recommended as the replacement test for faecal occult blood testing by NICE. We audited qFIT use in two week-wait (2WW) referrals in Somerset Foundation Trust (SFT) following its introduction in 2019.

Method
Following qFIT being made available to general practitioners, all 2WW referrals received before (July 2019) and after (December 2019) the introduction of the new 2WW referral form were reviewed. Electronic patient records were analysed to determine investigations performed and if a diagnosis of cancer was made.

Results
July 2019: 288 2WW referrals with 74 patients eligible for qFIT – only 7 of these underwent qFIT; total of 93 qFIT performed by GPs with 11 positive tests. December 2019: 222 2WW referrals with 18 patients eligible for qFIT – all of whom underwent qFIT; total of 155 qFIT performed by GPs with 18 positive (and 137 negative) tests. 1 patient with a positive qFIT was found to have colorectal malignancy (qFIT = 267 g/dL, investigation showed benign TVA). An increase in qFIT was observed over time, coinciding with a reduction in 2WW referrals, including reduction in patients who were qFIT eligible. The 2WW service identified 11 (3.8%) cases of colorectal cancer in July 2019 compared to 12 (5.4%) cases in December 2019, showing an increased pickup rate.

Conclusions
High proportions of 2WW referrals undergo investigation. The results of this audit highlight the utility of qFIT in screening 2WW referrals and reducing burden on the service, particularly where access to investigations is severely restricted due to coronavirus.