Case 33-1979: Intestinal perforation with retroperitoneal abscess extending to hip.
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Diagnosis, Differential↗
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[As lumbago treated, delayed diagnosis of large intestine perforation with extremely severe peritonitis--case report with focus on the value of diagnostic laparoscopy].
We report on a colon perforation with peritonitis which remained clinically undetected until the 4th day post trauma although the patient suffered from lumbalgia-like symptoms. He then developed an acute abdomen with sudden onset, being caused by a sigmoidal rupture and a consecutive diffuse peritonitis. A colon resection was performed according to the Hartmann procedure. Almost 36 revisions were necessary due to necrosis and perforation. Having treated the peritonitis successfully it was possible to close the abdomen and to remove the stomata. The case is discussed in relation to standard diagnostic procedures while a special interest is focused on the usage of sonography, explorative laparoscopy and laparotomy. We finally introduce the algorithm being applied to similar cases at our trauma center.
Abdomen, Acute↗
Late clinically silent perforation of intestinal non-Hodgkin's lymphoma.
The combined positron emission tomography/computed tomography scan is ideal in the initial staging of lymphomas and for evaluating the response to treatment. In posttreatment studies, the presence of a residual, metabolically active mass at the site of initially documented lymphoma is not expected to be anything other than residual active disease. We describe a case of intestinal non-Hodgkin's lymphoma that responded to chemotherapy but with a residual metabolically active mass at the site of initial disease. This mass was revealed to be a clinically silent closed intestinal perforation with abscess formation. Similar conditions should be kept in mind during the interpretation of posttreatment combined positron emission tomography/computed tomography scan and before exposing the patient to additional chemotherapy.
Aged↗
Typhoid perforation of the intestine.
We reviewed 91 cases of intestinal perforation complicating typhoid fever treated at a rural hospital in Haiti over a ten-year period. Surgical management involved simple primary closure of the perforation (80 patients), small-bowel resection with anastomosis (two patients), simple drainage of the peritoneal cavity (two patients), and serosal patching of the perforation (one patient). Six patients died before surgery. The mortality was 30.8% for all 91 cases but 21.2% for those treated with primary closure of the perforation. We also reviewed the literature pertaining to the management of intestinal perforation complicating typhoid fever.
Adolescent↗
Spontaneous small bowel perforations due to intestinal tuberculosis should not be repaired by simple closure.
Intestinal tuberculosis is a major problem in many regions of the world. The incidence of it is rising in Western countries due to immigration from Third World countries and human immunodeficiency virus infection. The difference between the simple closure and resection and anastomosis was evaluated in this study. Retrospectively, 12 patients with intestinal tuberculosis diagnosed histopathologically among 50 patients with free intestinal perforations operated on between 1995 and 2003 at Turgut Ozal Medical Center were evaluated. Each patient underwent routine laboratory tests and radiologic studies. The most common symptoms of patients were abdominal pain, night sweats, and weight loss. Sites of perforation were ileum in 10 patients (multiple perforation in 4) and jejunum in 2 patients (both had multiple perforations). The perforation was closed by primary closure in 7 patients. Resection-anastomosis was performed in 5 patients. Leaks occurred in overall 3 of 7 patients with primary closure. Three of the 7 patients with leaks due to septicemia died. The mortality rate among all patients was 25%. Intestinal tuberculosis should be kept in mind as a cause in free intestinal perforations. Because of high mortality rate, the resection of the affected area and anastomosis may be the treatment of choice rather than primary closure.
Adult↗
Peritoneal dialysis in neonates after major abdominal surgery.
Three newborn babies with acute renal failure were started on peritoneal dialysis 3, 4 and 3 days after abdominal surgery for intestinal perforation, intestinal malrotation with volvulus and hepatic laceration, respectively. Peritoneal access was achieved by Trocath catheters in the first two and via a Jackson-Pratt peritoneal drain inserted during surgery in the third baby. Two babies survived after dialysis for 9 and 6 days. The third baby was dialysed for 16 days, had partial recovery in renal function and died of multisystem failure at the age of 35 days. Peritoneal dialysis is possible in neonates with recent major abdominal surgery. Occasionally, a peritoneal drain inserted during surgery may provide an easy access for the procedure.
Acute Kidney Injury↗
[Endotoxin in diffuse suppurative peritonitis].
Endotoxin has been measured in the blood and peritoneal fluid from 28 patients with diffuse peritonitis after intestinal perforation, intestinal obstruction or mesenteric infarction. Phenol-Water-Extraction for plasma preparation has been used. Endotoxin in correlated with the clinical state in these patients.
Adolescent↗
[Perforation of the large intestine].
AIM: The aim of this study was to evaluate surgical options and therapeutic results of the large intestine perforation treatment, conducted by the authors' team. METHODOLOGY: During a four-year-period, a retrospective study including 53 patient subjects suffering from the large intestine perforation followed by peritonitis was conducted by the authors' team. The peritonitis-related risks were classified according to the Mannheim Peritonitis Index--the MPI score. RESULTS: The mean value of the MPI score reached 24.4 points in the assessed group. The total mortality rate reached 18.9% in the assessed group. The MPI score was significantly lower in the surviving patients group, compared to the exited patients group. Furthermore, the MPI score was significantly lower in the group of patients suffering from benign disorders of the large intestine, compared to the group of patients with malignancies. Resection with primary anastomosis (RPA), as a surgical treatment method, was successful in 32.1% of all cases in the group and in 73.9% of the patients treated using RPA. CONCLUSION: In indicated cases, the RPA method remains the appropriate surgical approach for the patients with the large intestine perforation, even when diffuse peritonitis concurs. The MPI score represents a simple and sufficiently reliable assessment system for the patients suffering from the large intestine perforation.
Adolescent↗
[Perforation of the intestine by a peritoneal tube 10 years after a ventriculo-peritoneal shunt].
A case is reported of intestinal perforation by a ventriculoperitoneal shunt (V-P shunt) tube 10 years after V-P shunt. A 49-year-old male received V-P shunt for normal pressure hydrocephalus following subarachnoid hemorrhage. Ten years later he was admitted to our department with an abscess on the anterior chest and on the abdominal wall along the shunt tube. When CT scan revealed that the peritoneal tube had perforated the bowel, the shunt was removed. During the operation it was found that the peritoneal tube was wrapped with fibrous tissue and that it had perforated the intestine. The subcutaneous abscess healed after the patient received systemic antibiotics. He was discharged and returned to work. We discussed the mechanism of bowel perforation in this case. It is assumed that bowel perforation occurred because of continuous friction at the same site of the bowel wall after the peritoneal tube received fibrous encasement in the abdominal cavity. Bowel perforation was diagnosed ten years after the V-P shunt in this case. To our knowledge, this is the longest period amongst reported cases.
Equipment Failure↗
[Perforation of small intestinal during hematologic recovery in an elderly man after induction therapy for acute lymphoblastic leukemia L3].
A 67-year-old man with a 7-month history of dilated cardiomyopathy was admitted to our hospital because of general fatigue, shortness of breath, and anemia on laboratory examination. Increased blasts were observed in the bone marrow. The blasts were characterized by large cells with abundant, intensely basophilic, vacuolated cytoplasm, round nuclei, and prominent nucleoli. Chromosome analysis revealed a nonrandom t(8;22)(q24;q11) chromosomal abnormality, and surface-marker analysis disclosed a positive immunophenotype for CD10, CD19, CD20, CD38, HLA-DR, FMC7, and IgM-lambda. These findings yielded a diagnosis of L3 acute lymphoblastic leukemia. The patient was treated with chemotherapeutic agents. On the 39th hospital day, during hematologic recovery after induction therapy, abdominal pain developed. Abdominal X-ray films disclosed ileus with dilatation of the small bowel and Kerckring's folds. Conservative treatment was begun but the patient died. At autopsy, intestinal perforations were observed at a site 55 cm proximal to the ileocecal junction. A specimen of perforated tissue revealed a diffuse infiltration of leukemic cells through the small bowel wall. However, bone marrow specimens showed no signs of aggravation of leukemia.
Aged↗
Clinical aspects of ulcerative colitis in mainland China.
Inflammatory bowel disease (IBD), including Crohn's disease (CD) and ulcerative colitis (UC), is reported to be increasing in incidence and prevalence in provinces and cities in mainland China. This article specifically reviews clinical features, extra-intestinal manifestations, complications, diagnosis and differential diagnosis, and medical treatment of UC. Compared to patients in Western countries, more mild to moderate and left-sided colitis cases were observed in a nation-wide study in China. Complications included anal fistula, anal abscess, anal fissure, severe bleeding, intestinal perforation, intestinal obstruction and colonic carcinoma. The extra-intestinal manifestations were arthritis/arthralgia, eye and skin disorders and oral ulcers. The high specificity of antineutrophil cytoplasmic antibody may useful for distinguishing UC from infectious colitis; in addition, serum levels of anti-saccharomyces cerevisiae antibody may be helpful for distinguishing between UC and CD. Oral sulfasalazine and 5-aminosalicylic acid (ASA) remain the mainstays for the management of mild to moderate UC in China. Corticosteroids and immunosuppressive agents are also widely used in severe or refractory UC.
Aminosalicylic Acids↗
Operative gastric perforation: a rare complication of ventriculoperitoneal shunt.
Complications of ventriculoperitoneal shunts are reported in 24-47 % of cases. These include mechanical malfunction and infection, cerebrospinal fluid collection, shunt migration, and visceral perforation. Intestinal perforation, most commonly colonic, may be associated with meningitis or cerebral abscess. Gastric migration has been previously described as a late complication related to the use of stiff Raimondi coil-spring peritoneal catheters in children with malnutrition and abdominal adhesions. We report a case of operative gastric perforation, a rare complication which was detected prior to development of symptoms.
Dandy-Walker Syndrome↗
Reactive arthritis associated with Shigella dysenteriae type 1 infection.
Shigella dysenteriae type 1 causes the most severe form of bacillary dysentery. The spectrum of illness ranges from mild watery diarrhoea to severe bloody diarrhoea. Shigellosis is often associated with intestinal complications, including intestinal perforation, intestinal obstruction, toxic dilatation of the colon, and prolapse of the rectum; systemic complications include septicaemia, hyponatraemia, hypoglycaemia, seizure, encephalopathy, haemolytic-uraemic syndrome, and malnutrition. Arthritis and conjunctivitis are rare extra-intestinal complications of shigellosis. Annually, about 110,000 patients receive treatment in the Dhaka Hospital of the International Centre for Diarrhoeal Disease Research, Bangladesh for diarrhoea and diarrhoea-associated illnesses, of which 11% are due to shigellosis. However, arthritis associated with shigellosis has not been reported from this population. Arthritis has been reported in association with infection due to S. flexneri and S. sonnei from other places. We are unaware of any reported case of arthritis in association with S. dysenteriae type 1 infections. In this report, we describe the clinical and laboratory features of a young woman who developed arthritis following S. dysenteriae type 1 infection.
Adolescent↗
[An approach to operative treatment for acute abdomen complicated by malignant hemopathy].
The experience of operative treatment in 14 cases of acute abdomen complicated by malignant hemopathy was reported. Primary diseases consisted of AL, NHL, MM, MH and MDS-RA, 13 cases of them were at progressing stage. The acute abdominal conditions included acute appendicitis, acute pancreatitis, acute cholecystitis, peritonitis secondary to intestinal perforation, intestinal obstruction, primary peritonitis and ileocecal syndrome. The type of acute abdomen was related with primary desease and chemotherapy. 8 cases were operated and 2 of them died of complications after operation. Biopsy of excised tissue showed tumor cells in 2 cases. The rate of correllation between preoper active and postoperative diagnosis was 62.5%. These findings suggest that malignant infiltration in the viscera, duration of abdominal pain before operation and the change of blood picture are the major factors for determining operative indication and the postoperative prognosis.
Abdomen, Acute↗
[Perforation of the small intestine in systemic diseases].
Small intestine perforations caused by systemic disorders are, except with M. Crohn, extremely rare. Therefore we report two cases of "spontaneous" small intestine perforations: one with hypersensitivity angiitis and one with Moya-Moya-disease, the latter not yet described in the literature.
Adult↗
Perforation of the intestine by a Raimondi peritoneal catheter. Case report.
The authors report a case in which the cut end of a Raimondi peritoneal catheter apparently caused intestinal perforation and contamination of the shunt system. The authors advise that if this type of catheter is to be divided the cut should be distal to the end of the sharp wire contained in it, which otherwise will protrude.
Brain Diseases↗
[Non septic, surgical complications and their treatment of acute necrotizing pancreatitis in 131 cases].
The authors analyse non septic, surgical complications and their treatment in 131 patients with acute necrotizing pancreatitis. Bleeding occurred in 13 patients 16 times. There were 3 cases with large intestine perforation, small intestine perforation twice in one patient and hydrothorax in 12 patients. The patients APACHE-II score was in the range of 15, 5, which was quite high. They experienced complications such as bleeding and bowel perforations mostly in those who underwent several reoperations. For the bleeding from acute duodenal ulcer conservative and surgical therapy (suturing) was executed. In the cases of intraabdominal bleeding they used several options such as, ligature, collagen mesh, Surgicell net and tamponation. Large intestine perforations were surgically treated with Hartmann's procedure or loop colostomy. The small intestine perforation was simply sutured. From the 12 patients with hydrothorax 8 underwent thoracic drainage. We lost 7 patients with bleeding, 3 with bowel perforations and 2 with hydrothorax. The authors believe that complications during therapy of acute necrotizing pancreatitis are high risk factor, but their treatment is not hopeless.
APACHE↗
Perforation of the small intestine due to eosinophilic gastroenteritis.
A 74-year-old woman with longstanding diarrhea and clinical symptoms of malabsorption and a raised peripheral eosinophilic count underwent an explorative laparotomy for small intestinal perforation. The resected specimen was consistent with the diagnosis of eosinophilic gastroenteritis. Despite corticosteroids, a second acute abdominal crisis occurred and the patient died. Small intestinal perforation due to transmural bowel wall involvement in eosinophilic gastroenteritis has to our knowledge not been described previously.
Aged↗