No abstract

Letters to the Editor should be submitted online to www.editorialmanager.com/ amsurg. (See details online under ''Instructions for Authors''.) They should be no more than 3 double-spaced pages excluding an Abstract and sub-headings with a maximum of four (4) references. If figures are included, they should be limited to two (2). The cost of printing color figures is the responsibility of the author.

No abstract

Background. A female patient presented four years following spontaneous bladder rupture with a recurrent spontaneous bladder rupture. Summary. Urinary bladder rupture is a condition usually caused by trauma or surgical instrumentation. Spontaneous bladder rupture is a much more uncommon condition and is associated with intoxication, radiation, stricture, or neurogenic bladder. We describe a case of a 40-year-old woman with a history of three caesarian sections with an idiopathic recurrent spontaneous bladder rupture. Originally, she presented with one day of worsening severe abdominal pain. CT showed possible ischemic bowel. She was taken to the operating room (OR) and found to have a bladder rupture. This was repaired, and she did well postoperatively. Four years later, she presented to the emergency department (ED) with one week of worsening abdominal pain that became severe acutely. Given that she had a similar issue four years prior the patient was suspicious, her bladder was again ruptured. CT cystogram showed contrast extravasation into the peritoneum. The patient was taken urgently to the operating room for an open repair of the bladder rupture. She did well following the procedure. Conclusion. Spontaneous bladder rupture is a surgical emergency and should be in the differential diagnosis of any patient with peritonitis with elevated creatinine and free intraperitoneal fluid. This diagnosis should especially be considered if the patient has a history pelvic radiation, neurogenic bladder, or intoxication. We submit that a history of multiple pelvic surgeries should be included in this list. CT cystogram is the diagnostic test of choice. Operative repair is generally the treatment for this condition.

Background. A 76-year-old male patient who suffered small bowel anastomotic dehiscence believed to be a complication provoked by Clostridioides difficile enteritis. Case Presentation. The patient was a 76-year-old male who underwent small bowel resection with primary anastomosis for a small bowel obstruction. On postoperative day #7, he rapidly decompensated and upon return to the operating room was found to have complete anastomotic dehiscence with copious enteric spillage. The presentation appeared as if the staple line had burst open. Enteric contents confirmed the diagnosis of Clostridioides difficile enteritis. Subsequent hospital course was complicated by ventilatory-dependent respiratory failure, hemodynamic instability, and persistent anemia secondary to gastric ulcer requiring endoscopic cauterization. After a prolonged hospital course, he eventually progressed and was transferred to a skilled nursing facility on hospital day #42. Discussion. Clostridioides difficile causes inflammation and copious large volume secretions that would theoretically increase intraluminal pressures creating an internal tension. This tension along with other factors from the infection itself would likely be inhibitory of anastomotic healing. Although it is rare, Clostridioides difficile enteritis is being reported with increasing frequency, and in the setting of recent small bowel anastomosis, it should be considered a possible risk factor for anastomotic leak.