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Background The use of Focused Assessment with Sonography for Trauma (FAST) in combination with computed tomography (CT) has become the mainstay of diagnostic workup in patients with suspected intraabdominal hemorrhage (IAH). However, diagnostic peritoneal aspiration (DPA) can be an important adjunct in hemodynamically unstable patients. The aim of this study was to evaluate the utility and diagnostic accuracy of DPA in detecting IAH. Methods Retrospective analysis of all patients who presented to the LAC+USC Medical Center and underwent evaluation with DPA between January 2010 and December 2016. Intraoperative, CT, and autopsy findings were used as gold standards in determining the diagnostic accuracy of DPA for the detection of IAH. Results A total of 73 consecutive patients were included in the study. The median age was 42 years (interquartile range [IQR]: 25-56), median injury severity score was 29 (IQR: 21-41), and 82.2% sustained blunt trauma. The most common indications for DPA were hemodynamically unstable patients with suspected IAH and patients with return of spontaneous circulation following resuscitative thoracotomy. Overall, the positive and negative predictive values of DPA were 89.4% and 88.9%, respectively. In 14 cases (19.2%), DPA correctly identified false positive/negative FAST results. Conclusion Our data suggest that DPA has high diagnostic yield for IAH. The use of DPA should be considered in unstable patients with inconclusive FAST results who cannot safely be evaluated with CT.

Relevance. Ectopic pregnancy is an urgent condition which may lead to intraabdominal hemorrhage and woman death. In recent years, the frequency of this pathology is significantly increasing. However, morphological changes in the fallopian tubes in patients with this disease remain understudied. Aim. To study morphological changes in the fallopian tubes in patients with ectopic pregnancy with various variants of the clinical course. Materials and methods. The morphological study included 130 patients who had laparoscopic surgery for ectopic pregnancy. Comprehensive morphological study of the fallopian tubes removed during surgery was conducted. Results and discussion. The article presents the morphological changes in the fallopian tubes in patients with ectopic pregnancy. Implantation of a fertilized egg in the fallopian tube led to significant changes in its macro- and microstructure, which were due to invasion of the chorionic villi and involved all layers of the tube wall, differing only in depth and prevalence. The most pronounced morphological changes in various segments of the tube were revealed in the endosalpinx. Conclusion. The combination of morphological changes in different layers of the tube is related to a chronic non-specific productive endomyosalpingitis with luminal deformation, which was one of the main causes of this disease development.

Rupture of superior mesenteric artery aneurysm (SMAA) is a very rare and life-threatening condition, presenting with acute intraabdominal hemorrhage.The patient was hospitalized upon complaint of nonspecific severe abdominal pain. Diagnosis of SMAA was established by abdominal Doppler ultrasound that showed a pseudo-aneurysmal lesion with size of 76 × 47 mm at the superior mesenteric main branch. Endovascular stenting was not performed because of the wide neck in the segment of the jejunal branches from SMA and the risk of branch loss during treatment. On the second day of hospitalization, the patient developed an acute abdomen. At explorative laparotomy for intraabdominal bleeding, the root of superior mesenteric artery was immediately and temporarily clamped to provide bleeding control. Aneurysmal tissue was resected and affected part was repaired by Dacron prosthetic graft to maintain proximal and distal vascular continuum. Intestinal viability was preserved. The patient survived disease-free as verified by his 18-month postoperative physical examination.The patient presents a very rare case showing ability to perform emergent intestine-sparing vascular surgery in ruptured SMAA. Surgery or endovascular treatment options should not be delayed especially in pseudo-aneurysms. It is critical to include ruptured SMAA in differential diagnosis of intraabdominal bleeding.

Although life-saving, cardiopulmonary resuscitation (CPR) has been associated with traumatic injuries in adult patients surviving cardiac arrest. In addition to rib and sternal fractures, intraabdominal injuries have also been shown to occur, particularly after prolonged external cardiac massage. Early detection of these injuries remains difficult and is often masked by concomitant hemodynamic instability and the higher likelihood of other injuries such as retroperitoneal hemorrhage. Accurate diagnosis is further complicated when venoarterial (VA) extracorporeal membrane oxygenation (ECMO) is instituted. As such, it is imperative for ECMO providers to maintain a high index of suspicion for intraabdominal/intraperitoneal solid organ injury and hemoperitoneum when managing patients who survive prolonged cardiac arrest. Furthermore, fluctuating or low ECMO circuit flow rates despite volume infusion may serve as indicators of intraabdominal bleeding and should be promptly assessed.

Transesophageal echocardiography (TEE) has been frequently used to identify potential etiologies of intraoperative cardiac arrest for noncardiac surgical patients. However, rescue TEE to assist in the diagnosis of intraabdominal hemorrhage has never been reported. We present a patient who developed cardiac arrest on emergence after an elective abdominal surgery. Intraoperative TEE revealed hypovolemia with hyperdynamic left and right ventricles. It also demonstrated a 3.3- by 13.2-cm circular perihepatic fluid collection on transgastric views raising concern for major intraabdominal hemorrhage as the cause for the cardiac arrest. This prompted surgical reexploration, which confirmed the diagnosis. We suggest that transgastric views to identify intraabdominal fluid collections should be considered during a rescue TEE if intraabdominal hemorrhage is suspected.

Acute pancreatitis is acute inflammation of pancreatic cells that may presents with non-specific findings such as abdominal pain and vomiting. Haemorrhage is a rare complication of acute pancreatitis, while complications such as pseudocyst, abscess, necrosis may also occur. Here, we present a case of 39-years-old male patient with intraabdominal bleeding due to idiopathic acute pancreatitis. Patient presented to emergency department with abdominal pain and lack of appetite; as a result of history, findings and investigations acute pancreatitis were considered. Oral feeding was stopped and nutritional support was given by vascular access and pain control was achieved. Due to decrease in hemoglobin and hemotacrit level diagnostic laparoscopy were performed. On exploration fragile and hemorrhagic pancreas was observed. Bleeding control was achieved; after symptomatic treatment abdominal pain regressed. Laboratory findings were completely recovered and patient was discharged. As a result; should also be noted that the rare complications of acute pancreatitis, such as hemorrhage,can be seen , so considering the patient's symptoms can mislead us further investigations should be made., Akut pankreatit, karın ağrısı ve kusma gibi özgül olmayan bulgularla seyreden akut pankreas hücre inflamasyonudur. Akut pankreatit sonrası pseudokist, apse, nekroz gibi komplikasyonlar görülebilirken hemoraji nadir görülen bir komplikasyondur. Burada idiopatik nedenle oluşan, 39 yaşında erkek bir hastada görülen, akut pankreatite bağlı intraabdominal kanama vakası sunulmuştur. Karın ağrısı ve iştahsızlık şikayetleriyle acil servise başvuran hastada; alınan anamnez, bulgular ve yapılan tetkiklerin sonucu olarak akut pankreatit düşünüldü. Hastanın oral beslenmesi kesilerek, beslenme desteği damar yolu ile verildi ve ağrı kontrolü sağlandı. Takibinde hemoglobin ve hematokrit seviyesinin düşmesi sebebiyle diagnostik laparoskopi yapıldı. Eksplorasyonda pankreas frajil ve hemorajik izlendi. Kanama kontrolü sağlandı; semptomatik tedaviler uygulandı; sonrasında karın ağrısı geriledi. Laboratuvar bulguları tamamen düzelen ve ek şikayeti gelişmeyen hasta şifa ile taburcu edildi. Sonuç olarak; akut pankreatit olgularında hemoraji gibi nadir görülen komplikasyonların da olabileceği unutulmamalı, hastanın bulgularının bizi yanıltabileceği düşünülerek ileri tetkik yapılmalıdır.

BackgroundWe hypothesized that slow crystalloid resuscitation would result in less blood loss and a smaller hemoglobin decrease compared to a rapid resuscitation during uncontrolled hemorrhage.MethodsAnesthetized, splenectomized domestic swine underwent hepatic lobar hemitransection. Lactated Ringers was given at 150 or 20 mL/min IV (rapid vs. slow, respectively, N = 12 per group; limit of 100 mL/kg). Primary endpoints were blood loss and serum hemoglobin; secondary endpoints included survival, vital signs, coagulation parameters, and blood gases.ResultsThe slow group had a less blood loss (1.6 vs. 2.7 L, respectively) and a higher final hemoglobin concentration (6.0 vs. 3.4 g/dL).ConclusionsUsing a fixed volume of crystalloid resuscitation in this porcine model of uncontrolled intraabdominal hemorrhage, a slow IV infusion rate produced less blood loss and a smaller hemoglobin decrease compared to rapid infusion.

BackgroundWe hypothesized that slow crystalloid resuscitation would improve blood loss and hemoglobin compared to a rapid resuscitation during uncontrolled hemorrhage.MethodsAnesthetized, splenectomized domestic swine underwent hepatic lobar hemitransection. Lactated Ringers was given at 150 or 20 mL/min IV (rapid vs. slow, respectively, N = 12 per group; limit of 100 mL/kg). Vital sign monitoring and serum testing was done for up to 180 min, followed by necropsy.ResultsSurvival was 7 vs. 8 out of 12 subjects, rapid vs. slow respectively (p>0.05). The slow group had a less blood loss (1.6 vs. 2.7 L, respectively) and a higher final hemoglobin concentration (6.0 vs. 3.4 g/dL).ConclusionsUsing a fixed volume of crystalloid resuscitation in this porcine model of uncontrolled intraabdominal hemorrhage, a slow IV infusion rate produced less blood loss and a higher hemoglobin level compared to rapid infusion.

In this case report, we aimed to present an 18-year-old male patient who had ruptured testicle after severe testicular trauma that developed due to a motorcycle accident. An eighteen-year-old male patient was brought to the emergency service after a motorcycle accident. There were open fractures in the left arm and left leg. The scrotum was ruptured, both testicles were outside, and the right testicle was ruptured. The patient was underwent emergency surgery for intraabdominal hemorrhage and liver laceration by general surgery. Also urology joined the operation. Urology carried out right orchiectomy and left testicular fixation on the patient. Although rupture of testicles is a rare condition, it may accompany the diagnosis in patients with multiple traumas. Early urology consultation should be sought to be able to save testicles and minimize complications.

Segmental arterial mediolysis (SAM) is a rare vasculopathy characterized by lysis of the outer media in splanchnic arteries and formation of dissecting pseudoaneurysms that may spontaneously rupture, leading to massive and often fatal intraabdominal hemorrhage. The pathogenesis of SAM is poorly understood. Healed SAM lesions closely resemble fibromuscular dysplasia (FMD), leading some authors to postulate that SAM represents a precursor to FMD despite distinct clinical differences between these two disorders. Herein, we present a 61-year-old woman with fatal SAM who showed histologic features in her aorta suggesting the opposite pathogenetic relationship, with an unclassified "FMD-like" arteriopathy preceding development of SAM.

SummarySpontaneous intraabdominal hemorrhage is a very rare event even in patients with bleeding disorders like hemophilia. Nevertheless this rare case must be considered in patients with coagulopathies presenting with abdominal pain. Prompt radiologic imaging and surgical consultation are of highest priority. Here we report on a 20-year-old patient with moderate hemophilia A, who underwent emergency laparotomy for a spontaneous idiopathic bleeding of the omentum majus. There are few cases in the literature on this sort of event in patients with hemophilia, who mostly suffer from spontaneous joint bleedings. These patients require an intensive, interdisciplinary perioperative care, involving haematologists, surgeons, radiologists and anesthesists. Finally we discuss, whether an optimized, individually adapted treatment with coagulation factors might possibly have prevented this bleeding event in this patient.

Intraabdominal hemorrhage remains one of the most frequent surgical complications after liver transplantation.The aim of the study was to evaluate risk factors for intraabdominal bleeding requiring reoperation and to assess the relevance of the reoperations with respect to short- and long-term outcomes following liver transplantation.Material and methods. Data of 603 liver transplantations performed in the Department of General, Transplant and Liver Surgery in the period between January 2011 and September 2014 were analyzed retrospectively. Study end-points comprised: reoperation due to bleeding and death during the first 90 postoperative days and between 90 postoperative day and third post-transplant year.Results. Reoperations for intraabdominal bleeding were performed after 45 out of 603 (7.5%) transplantations. Low pre-transplant hemoglobin was the only independent predictor of reoperation (p=0.002) with the cut-off of 11.3 g/dl. Postoperative 90-day mortality was significantly higher in patients undergoing reoperation as compared to the remaining patients (15.6% vs 5.6%, p=0.008). Post-transplant survival from 90 days to 3 years was non-significantly lower in patients after reoperation for bleeding (83.3%) as compared to the remaining patients (92.2%, p=0.096). Nevertheless, multivariable analyses did not reveal any significant negative impact of reoperations for bleeding on short-term mortality (p=0.589) and 3-year survival (p=0.079).Conclusions. Surgical interventions due to postoperative intraabdominal hemorrhage do not appear to affect short- and long-term outcomes following liver transplantation. Preoperative hemoglobin concentration over 11.3 g/dl is associated with decreased risk of this complication, yet the clinical relevance of this phenomenon is doubtful

Introduction. Heterotopic pregnancy is a life-threatening complication of pregnancy defined as coexistent intrauterine and ectopic gestation. Its diagnosis is frequently overlooked and delayed. Case Outline. A 28-year-old woman experienced acute abdominal pain in pregnancy achieved by in vitro fertilization. Since all previous checkups indicated a normal course of pregnancy, the ectopic pregnancy was not suspected on admission. However, due to persistent hypotension, this diagnosis was also considered. Transvaginal ultrasound performed by an experienced obstetrician revealed an adnexal mass highly indicative of ectopic pregnancy. No fetal heart beats were visualized and the diagnosis of a missed abortion was made. A prompt laparotomy revealed a ruptured right ampullary pregnancy, and salpingectomy was performed. Conclusion. Although rare, heterotopic pregnancy should be considered in the differential diagnosis of abdominal pain in pregnancy. Every physician treating women of reproductive age should bear in mind the possibility of heterotopic pregnancy not only in patients with predisposing risk factors but also in those without them.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) has become an increasingly popular alternative to emergency thoracotomy and aortic cross-clamping in patients with exsanguinating hemorrhage.1 This new capability is increasingly being used in non-trauma situations.2 3 This report demonstrates another novel use of REBOA for iatrogenic intra-abdominal hemorrhage.An 83-year-old man with multiple medical comorbidities and a history of chronic mesenteric ischemia was admitted to our institution for an elective mesenteric revascularization. Revascularization was unsuccessful, despite attempts to cross the lesion. Postprocedure, the patient developed a right groin hematoma, and CT on postprocedure day 0 demonstrated a femoral artery pseudoaneurysm and subintimal contrast at the level of the celiac artery, representing an iatrogenic dissection.The following day, he complained of dizziness. Physical examination revealed a blood pressure of 68/35 mm Hg, heart rate of 100 beats per minute, and a distended abdomen. Because the surgical intensive care unit (SICU) was full, he was transferred to the neurotrauma intesive care unit (NTICU) and intubated for hemodynamic instability. A chest X-ray revealed a prior thoracic endovascular aortic repair (figure 1), but no intrathoracic hemorrhage or pathology. Bedside ultrasonography revealed intra-abdominal fluid. Laboratory workup showed hemoglobin of 6.1 g/dL, from 10.9 the previous day. The patient was given two units of packed red blood cells, without response. The intensive care unit (ICU) team initiated norepinephrine, with minimal improvement despite increasing doses. Figure 1Chest X-ray with catheter in zone 1. Arrows mark the proximal and distal markers of the resuscitative endovascular balloon occlusion of the aorta.What would you do?Transfuse two units of packed red blood cells and observe.Proceed to the operating room (OR) for exploratory laparotomy.Endovascular balloon occlusion of the aorta (zone 1).

症例は48歳の女性で，突然の右季肋部痛のため当院を受診した．CTにて肝S8に径6 cmの腫瘤を認め，腹腔内に中等量の液体貯留を来していたことより腹腔内出血を来していたと考えられた．腫瘍は造影CTで動脈性早期濃染を伴い，MRIではT1強調画像で低信号，脂肪抑制T2強調画像で高信号であり典型的ではないが肝癌と診断した．待期的に肝部分切除を行った．病理組織学的検査では類上皮細胞のみからなる充実性，類洞状増殖を認め肝細胞癌類似の所見であったが，HMB-45陽性であることから肝血管筋脂肪腫と診断された．肝血管筋脂肪腫は血管，平滑筋，脂肪の成分をさまざまな割合で含むまれな良性腫瘍である．その多様性のため，画像・病理の診断が困難なことがある．肝血管筋脂肪腫の破裂は極めてまれであるが，術前診断が困難であること，悪性化の可能性があることなどからも，病態によっては切除の適応とすべきである．

In patients with traumatic intraabdominal hemorrhage, urgent decisions must be made. Resuscitation measures must often be simultaneously combined with diagnostic actions and measures to control the source of the bleeding. Hemorrhages are usually complicated by coagulation disorders and the presence of acidosis and hypothermia. In these conditions, emergency measures are required that usually involve various specialists. However, given the paucity of the scientific evidence in this field, the intervention protocols differ from one center to another. The European Guidelines for the management of bleeding following major trauma has recently been published. These guidelines review aspects such as evaluation and initial management of bleeding, localization and control of the source of bleeding and replacement of blood products. In addition, recommendations based on the best available evidence to 2008 are made. This review describes the basic aspects of traumatic intraabdominal hemorrhage.

症例は46歳，男性．腹痛を主訴に当院を受診し，腹腔内腫瘤の疑いにて当院内科より紹介．内視鏡検査では異常所見を認めず，腹部CTにて下腹部に造影効果を伴う6cm大の腫瘤を認め骨盤腔内にfluidを認めた．腹腔内腫瘤の診断で，平成16年11月22日手術を施行した．腹腔内には血性腹水（約150ml）を認め，Treitz靱帯から約210cmの回腸に壁外性の腫瘤を認めた．腫瘤には凝血塊が付着し少量の出血も認め，出血源と判断した．腫瘍を含めて，小腸を部分切除し端々吻合した．免疫染色でc-kitのみが陽性であり，GISTと診断した．術後約3年の現在，無再発生存中である．

目的:胃癌手術後の重篤な合併症のひとつとして，膵液漏に起因する腹腔内出血がある．同症例の治療方針について検討を行ったので報告する．対象と方法:1997年1月から2007年9月，当科で施行した胃癌切除症例1176例のうち，膵液漏に起因する腹腔内出血を認めた15例に対して行った治療と成績について検討を行った．結果:1176例中，78例（6.6％）に膵液漏を認め，うち15例（1.3％）に腹腔内出血を認めた．合併症の発生には，リンパ節郭清と合併切除による膵損傷が関与している可能性が示唆された．止血法として，IVRによる動脈塞栓術が，開腹止血術と同等の成績を示した．また，予後に関しても同等の成績であった．結語:胃癌術後の膵液漏による腹腔内出血時は，IVRによる動脈塞栓術を中心とする早期の対処が重要であると考えられた．

自然破裂による腹腔内出血を呈した退形成性膵管癌の1例を経験した. 症例は59歳の男性で, 腹痛を主訴に当院を受診した. 腹部US, CTにて膵体部腫瘍と多発肝転移を認めた.腹痛の増強を認めたため緊急入院し, CTにて腫瘍の著明な増大と大量の腹水が認められた. 試験的腹腔穿刺では血性腹水が吸引され腹腔内出血の診断で緊急開腹術を施行した. 腫瘍の破裂による出血と判明し, 膵体尾部切除術を施行した. 病理組織診断にて退形成性膵管癌と診断した. 術後, 化学療法を施行するも効果なく癌性悪液質が進行し, 術後18日目に死亡した. このように退形成性膵管癌は急速に増大する間に自然破裂を生じる可能性がある.

Die ovarielle Graviditat ist eine seltene, aber potenziell lebensbedrohliche Sonderform der extrauterinen Schwangerschaft. Die sichere praoperative und intraoperative Diagnosestellung ist schwierig. Pathogenetisch liegt der primaren Ovarialschwangerschaft eine Retention der befruchteten Eizelle im Ovar zugrunde. Das Hauptrisiko besteht in der Ovarruptur mit konsekutiver schwerer intraabdominaler Blutung. Allgemein gultige Therapieempfehlungen zum klinischen Management existieren nicht. In beschriebenem Fall wurde eine subakut perforierte Ovarialschwangerschaft intraoperativ diagnostiziert und eine partielle Ovarektomie per laparoscopiam durchgefuhrt. Das minimal-invasive operative Management sowie weitere mogliche Therapiemodalitaten werden erortert. Ovarian pregnancies represent a small fraction of ectopic gestations. They are especially feared due to their life-threatening intraabdominal hemorrhage. Pre- and intraoperative diagnosis is difficult. Pathogenetically ovarian pregnancy arises from the retention of a fertilized ovum in the ovary. General guidelines for the medical management are missing. In this case report, we diagnosed a subacute ruptured ovarian pregnancy during surgery and performed a partial ovarectomy via operative laparoscopy. Other therapeutic options in managing ovarian ectopic pregnancy will be discussed.

膵性腹水の治療中に腹腔内出血をきたした稀な症例を経験したので報告する.症例は57歳,男性,原因不明の腹水にて近医入院中に急性腎不全を引き起こし,当院へ紹介となった.当院入院時の腹部CTで大量の腹水と膵仮性嚢胞を認め,膵性腹水の診断で治療を開始した。腎不全に対しては透析導入を行った.入院5日目に突然の強い腹痛と腹部膨満感の増強が出現し,造影CTで膵嚢胞の増大とその内部への造影剤漏出を認めた.血管造影で中結腸動脈左枝に仮性動脈瘤を認め,そこから造影剤漏出を認めた.同血管ヘカテーテルを挿入できず緊急手術となった.開腹すると約7Lの血性腹水を認めた.膵尾部尾側に破裂した嚢胞を認め,それに接した横行結腸間膜の血管より出血を認めた.止血と壊死組織の除去を行い手術を終了した.膵仮性嚢胞の破裂から難治性腹水を生じ,さらに嚢胞内面に接した仮性動脈瘤の出血が嚢胞破裂部を通って腹腔内にまで及んだ稀な症例と考えられた.

Isolated peliosis of the spleen, characterized by the gross appearance of multiple cystlike, blood-filled cavities on cut surfaces of the organ, is a very rare pathologic entity that has been reported in 33 cases to date. We present 2 additional cases of isolated peliosis of the spleen observed at autopsy and confirmed by histology. In both cases investigated, cirrhosis of the liver was present. We hypothesize that local microcirculatory disturbances manifesting under altered local intravascular pressure conditions in the spleen may, at least to a certain degree, be responsible for the peliosis-associated vascular lesions. For the forensic pathologist, isolated peliosis of the spleen represents more than just another morphologic curiosity. The significance of peliosis lienalis lies in the potential of (1) overlooking the correct diagnosis as the cause of a spontaneous splenic rupture with intraabdominal hemorrhage, thus leading to the false conclusion of a violent death; and (2) misinterpreting the macromorphological appearance of this rare disease, also in the absence of splenic rupture, as a result of blunt force trauma.

Interstitial or cornual pregnancies represent a small fraction of ectopic gestations. They are especially feared due to their life-threatening intraabdominal hemorrhage. General guide-lines for the medical management are missing. In this case report, a special endoscopic conservative procedure using encircling suture and endoloop-technique was performed. This method provided an excellent tourniquet effect and resulted in effective hemostasis. In addition to our endoscopic treatment, other therapeutic procedures, such as primary methotrexate application will be discussed.

腹腔内出血で発症した回腸のGISTを経験したので報告する.症例は37歳の男性で下腹部痛を主訴に当院消化器科を受診した.来院時,下腹部に圧痛,筋性防御を認めた.白血球数は11,400/μLと高値を示したが,他に異常値を認めず,腹部単純X線検査でも異常を認めなかった.腹部CT検査で小腸に辺縁平滑で均一に濃染される4cm大の腫瘤を認め,下腹部には腹水が存在し, CT値から血性腹水と考えられた.以上の所見から小腸腫瘍による腹腔内出血と診断し,同日緊急手術を施行した.腹部正中切開で開腹すると,腹腔内には約800mlの血性腹水を認め,回腸末端部から約130cm口側の回腸に腸管外に発育する4cm大の腫瘍を認めた.腫瘍には凝血塊が付着しており出血源と診断した.腫瘍を含めて,回腸を約5cm切除した.腫瘍は,組織学的にはsmooth muscle typeのGISTと診断した.術後1年6カ月後の現在,無再発生存中である.

腹腔内出血を契機に発見された退形成性膵管癌 (巨細胞型) の1例を経験した. 症例は84歳の女性. 主訴は上腹部痛. 腹部US で腹水貯留と膵尾部の径4.5cm大の腫瘤を認め, 腹部造影CTで脾静脈から門脈本幹への陰影欠損と, 胃の大彎側に怒張した血管影を認めた. 緊急開腹術により, 怒張した大網静脈からの出血と判明し, 結紮止血術を施行した. また, 膵尾部腫瘤の組織生検にて, 膵巨細胞癌と診断されたが, 術後30日目に肺・肝転移を認めたため, 根治術の施行は断念した. その後, 膵腫瘤の増大・肝転移は進行するものの, 肺転移は術後1年目には消失するという稀有な経過をたどった. 本疾患は, 血管への浸潤性が高く, 自験例でも脾静脈の腫瘍塞栓による側副血行路の発達・怒張・破綻が腹腔内出血の原因と考えられた.本疾患の手術適応については, その極めて高い血行性転移率を考慮し, 慎重に検討する必要がある.

Injury due to go-karting accidents is a new kind of surgical emergency in Turkey and may show variations between patients. There are special details as relate to the design of the vehicles and patient characteristics. We report two seriously injured patients as a result of two different go-kart accidents. Severe intraabdominal hemorrhage due to liver laceration was seen in one patient and mesenteric intestinal avulsion in the other. Both patients were treated surgically and discharged uneventfully. Language: en

A case of ruptured aneurysm of the middle colic artery is reported. A 44-year-old woman was admitted to the hospital because of severe upper abdominal pain. After a few minutes from arrival, she fell into a shock state. Ultrasonotomography and computed tomography revealed intraabdominal hemorrhage. Angiography visualized a rupture of an aneurysm. Emergency operation was done and a large amount of blood with clot was present in the abdominal cavity. When the blood with clot was removed, a pulsatile bleeding site near the beginning of the middle colic artery was revealed. Since bleeding from the middle colic artery continued, the aneurysm was resected. The rupture of the aneurysm of the middle colic artery has been reported in only 14 cases in Japan. We find a great deal of difficulty in preopertive diagnosis, but the prognosis of the disease is good if early surgical hemostasis is successfully achieved. So the opportunity of the operation should not be missed.

Acute post-operative hemorrhage in the ICU can be difficult to diagnose accurately and in a timely fashion. There are many diagnostic studies available, some of which may delay timely diagnosis and treatment. This section reviews the diagnostic tests available and those that are most useful in the acute ICU setting of suspected post-operative or intraabdominal hemorrhage.