Necrotizing soft tissue infection (NSTI) is a rapidly progressive and potentially fatal infection that is most commonly bacterial in origin but can also be fungal. We present the case of a 79-year-old woman who developed NSTI after gastrostomy tube (G-tube) manipulation. She presented to the emergency department (ED) with abdominal pain and inflammation, and imaging revealed the G-tube to be positioned within the soft tissues. The patient then underwent emergent surgical debridement while decompensating from septic shock. Tissue cultures identified an unusual combination of Pichia and Lactobacillus species. The patient improved with repeated debridement and targeted antimicrobial therapy. This case highlights the importance of considering atypical and fungal sources of NSTI, especially in immunocompromised patients, as well as the critical nature of urgent surgical intervention.

Fornical ruptures, also known as calyceal ruptures, are a rare sequela of obstructive uropathy in most cases. This pathology can present with similar symptoms to urolithiasis, such as costovertebral tenderness, abdominal pain, nausea, and vomiting. Treatment of forniceal ruptures can vary based on the individual clinical presentation. It may be conservative with hydration, intravenous antibiotics, and pain control. It can also involve more invasive interventions such as stent placement, nephrostomy tube placement, and fluid aspiration. We present a patient with no history of urolithiasis, trauma, malignancy, or previous urologic interventions, who was found to have an obstructive uropathy by a three-millimeter stone that led to a right-sided forniceal rupture by computed tomography imaging. The patient was admitted to the general medical service with urology following for intravenous antibiotics, stent placement with cystoscopy, and lithotripsy.

Rectal foreign bodies (RFBs) represent an uncommon but challenging surgical emergency. While most cases result from intentional insertion for sexual gratification, accidental insertion is exceedingly rare. Management depends on the size, shape, location, and associated complications of the foreign body. We present a rare case of patient-reported rectal insertion of a health faucet nozzle resulting in rectosigmoid impaction that required laparotomy-assisted transanal extraction. A 40-year-old male presented with anorectal pain, scant bleeding per rectum, mucoid discharge, and lower abdominal pain following an accidental slip-and-fall injury in the bathroom while defecating. Clinical examination revealed a palpable RFB. Plain radiographs demonstrated a foreign body consistent with a plastic health faucet impacted at the rectosigmoid junction. Due to the object's large size, irregular configuration, and proximal location, transanal extraction was considered unsafe. The patient underwent an exploratory laparotomy, during which the foreign body was carefully milked distally to disengage the entrapped rectal mucosa and subsequently extracted transanally without enterotomy or bowel resection. Intraoperative findings included localized rectal wall bruising and mucosal edema without perforation. The patient had an uneventful postoperative course, characterized by the return of bowel function and satisfactory recovery, and was subsequently discharged in stable condition. Accidental rectal insertion of a health faucet is an exceptionally rare cause of rectosigmoid foreign body impaction. This case highlights the importance of careful clinical assessment, appropriate imaging, and individualized operative planning. Laparotomy-assisted transanal extraction can be a safe and effective strategy for the removal of large, impacted rectosigmoid foreign bodies while preserving bowel integrity and avoiding more extensive surgical procedures.

Advanced haemodynamic monitoring of cardiac index is restricted to selected high-risk cases, leaving most patients undergoing major surgery without real-time assessment. We aimed to develop and internally validate a simplified bedside score for continuous, minute-by-minute screening of low cardiac index using routinely available parameters. Retrospective single-centre study of adults undergoing major abdominal surgery with advanced haemodynamic monitoring (January 2023 to February 2026). Low cardiac index was defined as pulse contour cardiac index < 2.2 l.min[- 1].m[- 2]. The dataset was split 80/20 at the patient level. Twelve candidate features were ranked using SHapley Additive exPlanations (SHAP) values; the top five were used to fit a generalised linear mixed model, yielding the integer-weighted Low Cardiac Index (LCI) score. A rule-out threshold (sensitivity ≥ 0.90) was selected, and test-set performance was evaluated with patient-level cluster bootstrap. The analysis cohort comprised 136 patients and 42,346 timepoints (15.5% low cardiac index prevalence). The derived formula was LCI score = 57 + (2 × DBP) + (0.5 × Age) + PPV - HR - SBP. At a threshold of ≥ 30, the score achieved an area under the receiver operating characteristic curve of 0.84 (95% confidence interval 0.75, 0.91), sensitivity 0.92 (0.80, 0.99), and negative predictive value 0.97 (0.92, 1.00). Performance was stable across 20 random splits and outperformed individual haemodynamic parameters. The LCI score is a simple bedside rule-out tool for low cardiac index, with a score below 30 yielding a negative predictive value of 0.97. External validation and prospective assessment of clinical impact are warranted.

Uterine leiomyosarcoma (uLMS) is a rare and aggressive mesenchymal malignancy associated with a high risk of recurrence and metastatic spread. Although recurrent disease commonly presents with infiltrative or bulky pelvic masses, atypical patterns of dissemination may create diagnostic challenges. We present the case of a 49-year-old woman with a history of FIGO stage IB uterine leiomyosarcoma who underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy in 2023 and subsequently received treatment for recurrent metastatic disease. She presented with acute lower abdominal pain, persistent vomiting, and progressive obstipation. Computed tomography demonstrated a large heterogeneous pelvic mass measuring approximately 14 cm, together with features of a closed-loop small bowel obstruction and mesenteric vessel twisting suggestive of volvulus. Following clinical deterioration despite conservative management, emergency exploratory laparotomy was performed, revealing a 360-degree small bowel volvulus around the superior mesenteric artery pedicle, which was successfully reduced. A large fixed pelvic mass involving adjacent bowel and mesentery was identified, along with numerous smooth, firm, pedunculated nodules distributed throughout the mesentery, bowel serosa, and parietal peritoneum. These nodules had a gross appearance resembling benign parasitic leiomyomas or disseminated peritoneal leiomyomatosis rather than metastatic sarcoma. Segmental small bowel resection with double-barrelled ileostomy was undertaken due to bowel compromise and extensive serosal injury. Histopathological examination of the resected nodules demonstrated atypical spindle cells arranged in intersecting fascicles with moderate nuclear atypia and a mitotic rate of 5-10 mitoses per 10 high-power fields. Immunohistochemical analysis showed diffuse positivity for smooth muscle actin, desmin, and h-caldesmon, with abnormal mutant-pattern p53 expression, confirming multifocal metastatic uterine leiomyosarcoma. This case demonstrates an unusual pattern of metastatic uLMS presenting with a benign-appearing peritoneal distribution and complicated by acute small bowel volvulus and obstruction. The findings highlight the importance of histopathological and immunohistochemical assessment in distinguishing metastatic smooth muscle malignancy from benign-appearing lesions and emphasise the need for multidisciplinary management in complex recurrent disease.

Objective: Metagenomic sequencing was employed to analyze the pathogen detection profile in pediatric severe acute non-A-E hepatitis. Methods: Based on the platform of the China Childhood Severe Acute Hepatitis Collaborative Group, a case series study was conducted. This study enrolled 36 children with severe acute non-A-E hepatitis, who were admitted to 17 hospitals between April and July 2022. Clinical data, including etiological test results and liver function tests, were collected, and peripheral blood and nasopharyngeal swab specimens were obtained. Metagenomic next-generation sequencing (mNGS) was performed to detect potential infectious pathogens. Results: Among 36 children, there were 24 males and 12 females, with an onset age of 3.5 (1.1, 9.0) years. Common clinical symptoms were fever in 22 cases (61%), jaundice in 13 cases (36%), vomiting in 12 cases (33%), abdominal pain in 10 cases (28%), rash in 10 cases (28%), and diarrhea in 3 cases (8%). Serum alanine aminotransferase and aspartate aminotransferase levels were 950 (826, 1 404) and 811 (498, 1 295) U/L, respectively. Using PCR, plasma Epstein-Barr virus (EBV)-DNA was tested in 31 cases (86%) and plasma cytomegalovirus (CMV)-DNA in 25 cases (69%), and all results were below 5×10[5] copies/L. Plasma mNGS was performed on all 36 patients, detecting 11 viruses. These included EBV in 14 cases, CMV in 12 cases, human adenovirus in 2 cases, herpes simplex virus type 1 in 2 cases, adeno-associated virus type 2 (AAV2) in 1 case, and 6 other viruses. No patient tested positive for both human adenovirus and AAV2 simultaneously. Plasma mNGS results showed a viral read count of 4 (2, 10) per 1×10[8] reads. Nasopharyngeal swab mNGS was performed on 8 cases (22%), detecting 7 viruses. These included human herpesvirus 7 in 4 cases, EBV in 3 cases, and CMV in 3 cases, as well as 4 other viruses. Human adenovirus and AAV2 were not detected. Among the 4 children with human herpesvirus 7, 2 cases were also positive for human herpesvirus 6B, but neither virus was detected in their plasma mNGS. Conclusions: The detection rates of human adenovirus and AAV2 are both low among children with severe acute non-A-E hepatitis, and there are no cases of co-infection with both viruses.

Gastroparesis, a chronic motility disorder, is a diagnosis of exclusion that necessitates careful evaluation for structural and surgically correctable causes. Although the medical differential diagnosis emphasizes functional etiologies, anatomic abnormalities are often under-recognized despite guideline recommendations for thorough endoscopic and structural assessment. Symptoms such as nausea, vomiting, early satiety, and delayed gastric emptying may be indistinguishable from true motility disorders. We present two patients initially diagnosed with gastroparesis whose symptoms were ultimately driven by surgical pathology. Case 1 describes a 70-year-old woman with persistent nausea and vomiting, weight loss, epigastric abdominal pain, and delayed gastric emptying on scintigraphy, initially scheduled for gastric peroral endoscopic myotomy (G-POEM) for presumed gastroparesis. Intraoperative endoscopy revealed gastric volvulus as the underlying etiology, prompting conversion to definitive surgical repair. Gastric volvulus, while rare, may be complicated by ischemia or perforation, highlighting the importance of timely differentiation from gastroparesis. Case 2 describes a 53-year-old woman with intractable nausea, vomiting, and inability to tolerate oral intake following a Roux-en-Y gastric bypass (RYGB). Surgical exploration revealed a Roux-en-O configuration with twisted limbs causing impaired drainage, ultimately requiring bypass reversal and pyloroplasty. The Roux-en-O configuration is a rare but serious complication of RYGB involving misplaced anastomoses that create a blind loop, resulting in obstruction and gastroparesis-like symptoms. Clinicians should maintain heightened suspicion for structural pathology in patients with atypical presentations, previous surgery, or refractory symptoms, as delayed diagnosis can lead to life-threatening complications.

Gastric volvulus is an uncommon condition characterized by abnormal rotation of the stomach around one of its anatomical axes. Its diagnosis can be challenging because of its low incidence and nonspecific clinical presentation, particularly in elderly patients, and it may occur in association with a hiatal hernia. Delayed diagnosis may result in serious complications, including ischemia and perforation. Management should be individualized according to patient characteristics and surgical risk. We report the case of a 94-year-old woman with multiple comorbidities, including cardiovascular disease, chronic kidney disease, and long-term anticoagulant therapy, who presented with acute abdominal pain, abdominal distension, nausea, and hematemesis. CT revealed findings consistent with gastric volvulus without evidence of perforation. Given her elevated surgical risk, therapeutic endoscopy was performed, including gastric decompression, endoscopic reduction of the volvulus, and placement of a percutaneous endoscopic gastrostomy (PEG) for gastric fixation. The patient experienced immediate resolution of symptoms, with no procedure-related complications, and remained free of recurrence during 12 months of follow-up. This report highlights the successful use of endoscopic reduction followed by PEG as a long-term management strategy for gastric volvulus in a frail, high-risk surgical patient. It underscores the potential role of this minimally invasive approach in carefully selected patients who are not candidates for definitive surgical repair.

Irritable bowel syndrome is a common disorder of gut-brain interaction characterized by chronic abdominal pain and altered bowel habits in the absence of structural pathology. Its pathophysiology reflects a complex interplay between the central nervous system, enteric nervous system, microbiota, immune signaling, epithelial barrier dysfunction etc. Despite advances in the understanding of the mechanisms causing IBS, the diagnosis of IBS remains primarily symptom-based, necessitating the use of objective tools to improve diagnostic precision and personalized management. This review synthesizes highlights existing literature on IBS biomarkers, including inflammatory markers (cytokines, C-reactive protein), microbial signatures (gut microbiota composition, anti-CdtB and anti-vinculin antibodies), metabolic indicators (bile acids, short-chain fatty acids), and markers of intestinal permeability (zonulin) to assess their applications in the diagnosis and management of IBS. We also examined emerging multi-omics technologies that identify the complex patterns linking the gut, the brain and the microbiota. Early research focusing on single biomarkers demonstrated limited diagnostic utility due to the heterogeneous and multifactorial nature of IBS. Recent advances support the development of composite, mechanism-based biomarker panels that integrate multiple biological domains, offering improved representation of underlying pathophysiological processes. These developments mark a shift from a single-marker approach toward multidimensional biomarker strategies. This narrative review synthesizes current evidence and proposes a framework for integrating biomarkers into clinical practice. Biomarkers are best utilized following a positive symptom-based diagnosis and exclusion of alarm features, to stratify patients into biologically relevant subtypes and guide targeted therapy. This supports a transition from exclusion-based diagnosis of IBS towards a positive and more precise one.

Inguinoscrotal hernias account for ~2.7% of all inguinal hernias. Rare presentation limits the development of management guidelines for complex presentations of the condition. This case report reviews the management of an inguinoscrotal hernia containing perforated appendicitis with resultant necrotizing fasciitis. A 59-year-old male presented to the emergency department with worsening pain and edema in the right inguinal canal. Imaging revealed perforated appendicitis contained within an inguinoscrotal hernia, complicated by air in the abdominal wall consistent with necrotizing fasciitis. The patient was taken to the operating room for extensive wound debridement, appendectomy and orchiectomy with interval definitive hernia repair 48-h after index operation. This case demonstrates our success with a single 48-h operative interval, extended antibiotic course and biological mesh placement in the context of complicated inguinal hernia repair. Our experience with this patient should aim to inform future management of patients with similar conditions.