Umbilical hernia in the cirrhotic patient is frequently seen in the setting of refractory ascites. This article reports a rare case of spontaneous rupture of a recurrent umbilical hernia in a patient with persistent ascites, following an acute increase in intra-abdominal pressure, leading to bowel evisceration. This case highlights a potentially fatal complication of umbilical hernia in the setting of chronic ascites, which was successfully managed with prompt surgical intervention.

Dear Editor:We would like to share with the readers a unique case we had to deal with of aseptic abscess. Aseptic abscesses were first described 25 years ago by Andre et al. in a patient who presented with unexplainable abscesses that did not respond to antibiotics but improved when given steroid treatment. Research until date has shown a relationship between aseptic abscess and inflammatory bowel disease (IBD) and neutrophilic dermatoses of which largest study has been a case series. Our review of literature only revealed a total of 50 cases reported until date.Here, we would like report a case of sterile abscess in a 48-year-old female with quiescent Crohn's disease, presenting with failure to thrive that resolved after drainage and steroid treatment. She reported 1-month history of weakness, fever, and poor appetite. She also noted coughing and associated pain in the right lower chest. Her Crohn's disease had been under control more than 15 years without the need for treatment. On admission, her laboratory exam showed a white blood cell (WBC) count of 14 (×10 9 /L). She was worked up for fever of unknown origin. Upon abdominal imaging, a hypo-attenuating mass, measuring 3.8×2.5×2.4 cm, located in the left hepatic lobe was present. Nonspecific abdominal adenopathy was also discovered. An abscess was suspected and the patient was started on broad-spectrum antibiotic therapy. Aspiration was then performed, which removed 15 cc of purulent material from the lesion. The cultures of the aspirate were negative. The patient's clinical status did not improve, and her antibiotic therapy was discontinued. Steroid therapy was started, and the patient's status greatly improved. She was discharged 4 days after steroid therapy was begun. A repeat ultrasound 3 weeks later showed resolution of the abscess.It is well known that an aseptic abscess can be an extraintestinal manifestation of those diagnosed with inflammatory bowel disease. These lesions occur in 30-40 % of patients diagnosed with IBD and are the initial symptom in 10 % of presenting cases. Aseptic abscess and neutrophilic dermatoses have similar pathophysiology and can be reported in concurrence for those with IBD. We found that of the total 50 reported cases until date, 58 % cases involved the spleen followed closely by the lymph nodes and liver, respectively. The majority (>90 %) abscess are steroid responsive though have a relapse.Of particular note are summaries of reports in the literature of aseptic abscesses occurring in patients with Crohn's disease and ulcerative colitis that are mentioned below.

Computed tomographic virtual colonoscopy (CTVC) is a safe and minimally invasive modality when compared with fiberoptic colonoscopy for evaluating the colon and rectum. We have reviewed the risks for colonic perforation by investigating the relevant literature. The objectives of this study were to assess the risk of colonic perforation during CTVC, describe risk factors, evaluate ways to reduce the incidence complications, and to review management and treatment options. A formal search of indexed publications was performed through PubMed. Search queries using keywords “CT colonography,” “CT virtual colonoscopy,” “virtual colonoscopy,” and “perforation” yielded a total of 133 articles. A total of eight case reports and four review articles were selected. Combining case reports and review articles, a total of 25 cases of colonic perforation after CTVC have been reported. Causes include, but are not limited to, diverticular disease, irritable bowel diseases, obstructive processes, malignancies, and iatrogenic injury. Both operative and nonoperative management has been described. Nonoperative management has been proven safe and successful in minimally symptomatic and stable patients. Colonic perforation after CTVC is a rare complication and very few cases have been reported. Several risk factors are recurrent in the literature and must be acknowledged at the time of the study. Management options vary and should be tailored to each individual patient.