OBJECTIVES:While emergency cholecystectomy is the preferred treatment for acute cholecystitis, conservative management can be used as a bridge to definitive surgical management in situations where emergency surgical services are limited. The objective of this systematic review is to identify factors associated with conservative management failure as defined as either failed resolution of symptoms on initial presentation, or the recurrence of symptoms whilst awaiting an elective cholecystectomy. This study aims to allow clinicians to make evidence-based recommendations for conservative versus operative management. METHODS:A systematic review of the Medline database was conducted in May 2022 to identify studies analysing the success of non-operative management of acute cholecystitis. Two independent reviewers selected studies based on predefined criteria, and the risk of bias was evaluated. Out of the initial 1344 studies retrieved, 12 studies met the inclusion criteria. RESULTS:Factors significantly associated with persistence of symptoms in at least one study on multivariable analysis included diabetes mellitus, age >70, tachycardia, elevated temperature, elevated white cell count >15 000/uL and a distended gallbladder >5 cm. Factors significantly associated with recurrence of symptoms included Age <40 or >80, male sex, acute cholecystitis grade 2 or 3, elevated creatinine, serum albumin <4 g/dL, thickened gallbladder wall >5 mm. CONCLUSION:Several factors have been identified which may facilitate future evidence-based recommendations for tailored management strategies for patients with acute cholecystitis.

BACKGROUND Obesity represents a growing global health threat, which generally portends increased morbidity and mortality in the context of traumatic injuries. We hypothesized that there may exist a protective effect related to increased weight and truncal girth provided for obese patients in penetrating torso injuries, although this may not exert a significant positive impact overall upon clinical outcomes. METHODS A comprehensive review of the literature was conducted across five databases up to March 2021 (Medline, Pubmed, Embase, Web of Science and the Cochrane library) to examine the effect of obesity on penetrating thoracoabdominal injuries. The primary outcome was to determine the rate of nonsignificant injury and injury patterns. Secondary outcomes examined were lengths of stay, complications, and mortality. Comparisons were drawn by meta-analysis. The study protocol was registered with PROSPERO under CRD42020216277. RESULTS There were 2,952 publications assessed with 12 meeting the inclusion criteria for review. Nine studies were included for quantitative analysis, including 5,013 patients sustaining penetrating thoracoabdominal injuries, of which 29.6% were obese. Obese patients that sustained stab injuries underwent more nontherapeutic operations. Obese patients that sustained gunshot injuries had longer intensive care and total hospital length of stay. Obese patients suffered more respiratory complications and were at an increased risk of death during their admission. CONCLUSION The “armor phenomenon” does not truly protect obese patients, a population that experiences increased morbidity and mortality following penetrating thoracoabdominal injuries. LEVEL OF EVIDENCE Systematic Review and Meta-Analysis; Level IV.

A 72-year-old woman presented to the emergency department with sudden onset crampy, generalised abdominal pain. She had a history of peptic ulcer disease, chronic constipation, and heavy smoking. She was tachycardic and febrile, and had generalised peritonism. Her white cell count was 13·6 × 109 cells per L. CT showed pneumoperitoneum in the upper abdomen and pelvic free fluid without oral contrast extravasation (figure A, B). There was faecal loading without features of mechanical obstruction.

A previously healthy 20-year-old man presented with a 2-day history of right lower quadrant pain radiating into the right groin and testis. He was afebrile with no other associated symptoms. He had no previous operations and no known allergies. On examination, he had right iliac fossa tenderness and

A 27-year-old man presented with acute right upper quadrant abdominal pain and vomiting. He was clinically in hypovolaemic shock. Investigations revealed normocytic anaemia with a normal bilirubin and moderate liver function test abnormalities. CT abdomen and pelvis demonstrated haemoperitoneum and a large solitary hepatic mass in segments V and VI, suspicious for a ruptured hepatic tumour. Massive transfusion protocol was commenced and angioembolisation of the inferior branch of the right hepatic artery was undertaken. Despite this, his haemorrhagic shock was resistant to resuscitation. Thus, he underwent emergent exploratory laparotomy, which resulted in segments V and VI liver resection and packing. Re-look laparotomy 2days following initial exploration was performed where haemostasis was confirmed. Histopathology revealed a ruptured well-differentiated hepatocellular adenoma. The patient made a good recovery following a 2-week admission.

A 62-year-old patient was admitted with an acute unprovoked portal vein thrombosis with splenic and mesenteric extension. His progress was complicated by progressive small bowel ischaemia and increasing clot burden despite systemic anticoagulation. This case report describes the use of catheter-directed thrombolysis via a transjugular intrahepatic portosystemic shunt, with the disease and its treatment complicated by a ruptured iatrogenic pseudoaneurysm, abdominal compartment syndrome and small bowel infarction necessitating extensive small bowel resection.

Background/Aims: Medication non-adherence is common in inflammatory bowel diseases (IBD). The short-term consequences of non-adherence include increased disease relapse but the long-term impact upon patients in terms of daily functional impairment are less well characterized. Identifying negative outcomes, such as disability, may encourage adherence. Methods: Consecutive ambulatory IBD subjects completed the Medication Adherence Rating Scale (MARS; non-adherence defined as <= 16), Inflammatory Bowel Diseases Disability Index (IBD-DI; disability: <3.5) and Beliefs about Medicines Questionnaire (high necessity/concerns: >= 16). The primary outcome was the association between medication non-adherence and disability. Secondary outcomes were the predictors of these outcomes. Results: A total of 173 subjects on IBD maintenance medications were recruited (98 Crohn's disease, 75 ulcerative colitis: median IBD-DI, -5.0; interquartile range [IQR], -14.0 to 4.0 and median MARS, 19.0; IQR, 18 to 20) of whom 24% were non-adherent. Disability correlated significantly with medication nonadherence (r=0.38, P<0.0001). Median IBD-DI for non-adherers was significantly lower than adherers (-16.0 vs. -2.0, P<0.0001). Predictors of disability included female sex (P=0.002), previous hospitalization (P=0.023), management in a referral hospital clinic (P=0.008) and medication concerns (P<0.0001). Non-adherence was independently associated with difficulty managing bowel movements (odds ratio [OR], 3.71; 95% confidence interval [CI], 1.50-9.16, P=0.005), rectal bleeding (OR, 2.69; 95% CI, 1.14-6.36; P=0.024) and ardiralgia/arthritis (OR, 2.56; 95% CI, 1.11-5.92; P=0.028). Conclusions: Medication non-adherence was associated with significantly increased disability in IBD. Female gender, higher disease severity and medication concerns were additional predictors of disability.

Up to half of all patients with inflammatory bowel diseases (IBD) ultimately require bowel surgery, many due to disability from failed medical therapy. However, their long-term activity participation and functioning has not previously been quantified. The primary objective of this study was to evaluate the disability associated with surgical interventions in comparison and secondary aim was to identify predictors of disability. This prospective cross-sectional study recruited ambulatory IBD patients in remission from the IBD Sydney cohort and compared disability status in surgery versus non-surgery subjects. Disability was assessed using the validated Inflammatory Bowel Disease Disability index (IBD-DI) a quantitative tool that predicts workforce participation and quality of life with a threshold score of -3 indicating disability. Demographic and surgical predictive factors for disability were studied by multiple logistic regression. A total of 145 IBD cases were recruited (60 non-operative, 85 post-operative) with mean age of 46 years. There were 81 Crohn’s disease patients and 64 ulcerative colitis cases with 622 patient-years of follow up. Median time post-operative was 6 years. Significant predictors of disability were female sex with disability odds ratio (OR): 2.9, (95%CI: 1.4–6.1, P=0.005) and post-operative status OR: 3.5, (95%CI: 1.7 – 7.5, P=0.001). Compared against non-surgical patients, the OR of disability with intestinal resection and primary anastomosis, stoma and J-pouch were OR: 3.0, (95%CI 1.1 – 8.3, P=0.03), OR: 4.0 (95%CI 1.5 – 11.0, P=0.006) and 3.8 (95%CI 1.0 – 14.6, P=0.048) respectively. There was no significant difference in the odds ratio of disability between the different surgical procedures. Characteristics such as UC vs CD, age, time since surgery, or duration of illness were not significant predictors of disability. Female sex and prior surgical treatment for IBD are predictive of disability in IBD. Post-operative status may represent more severe IBD hence increasing level of disability.

Inflammatory bowel disease (IBD) is a chronic idiopathic inflammatory condition with intestinal and extraintestinal manifestations. Medications are the cornerstone of treatment of IBD. However, patients often adhere to medication poorly. Adherence to medications is defined as the process by which patients take their medications as prescribed. Treatment non-adherence is a common problem among chronic diseases, averaging 50% in developed countries and is even poorer in developing countries. In this review, we will examine the adherence data in IBD which vary greatly depending on the study population, route of administration, and methods of adherence measurement used. We will also discuss the adverse clinical outcomes related to non-adherence to medical treatment including increased disease activity, flares, loss of response to anti-tumor necrosis factor therapy, and so forth. There are many methods to measure medication adherence namely direct and indirect methods, each with their advantages and drawbacks. Finally, we will explore different intervention strategies to improve adherence to medications.