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PubMed2004

A clinical, microbiological, and pathological study of intestinal perforation associated with typhoid fever.

One of the most serious complications of typhoid fever is intestinal perforation. Of 27 patients admitted to a provincial hospital in the Mekong Delta region of Vietnam who had gastrointestinal perforation secondary to suspected typhoid fever, 67% were male, with a median age of 23 years and a median duration of illness of 10 days. Salmonella enterica subspecies enterica serotype Typhi (S. Typhi) was isolated from 11 (41%) of 27 patients; of 27 patients, only 4 (15%) had positive cultures from gut biopsies. S. Typhi DNA was detected by polymerase chain reaction for all perforation biopsy samples. Detailed histological examination of the gastrointestinal mucosa at the site of perforation in all cases showed a combination of discrete acute and chronic inflammation. Acute inflammation at the serosal surface indicated additional tissue damage after perforation. Immunohistochemical results showed that the predominant infiltrating cell types at the site of perforation were CD68+ leukocytes (macrophages) or CD3+ leukocytes (T lymphocytes).

Adult↗
PubMedDate not supplied

Spontaneous focal intestinal perforation in prematurity: report of three cases.

Three premature neonates with a localized perforation of the intestine, but not associated with necrotizing enterocolitis (NEC) or gastrointestinal anomaly are reported. The birth weight of these babies was around 1500 g and they exhibited striking similarities in the clinical course. Before laparotomy, NEC was firstly impressed. Abdominal distension, refusal of feedings, poor activity and respiratory distress were the major manifestations. Pneumoperitoneum was all detected before operation. The perforate site was terminal ileum in one and anterior cecum in the other two babies. The gastrointestinal tract was otherwise normal. The first case received segmental resection of the perforation with end to end anastomosis and the other two underwent ileostomy. Bacteria was discovered from the peritoneal fluid in the second and third cases, including E. coli, Enterobacter cloacae and Klebsiella pneumoniae respectively. The postoperative course was complicated with wound infection and adhesion ileus in two patients. Rectal suction biopsy in the second and third cases showed normal histology. Until present all three patients were uneventful. We concluded that premature or very low birth weight infants with spontaneous, localized gastrointestinal perforation and peritonitis had milder course than NEC, and if promptly diagnosed and treated, the prognosis is excellent.

Cecal Diseases↗
PubMed1996

Focal intestinal perforation in preterm infants is an emerging disease.

In order to elicit the pathogenesis of focal intestinal perforation in preterm infants we contrasted 8 infants who developed this disease with 16 gestation-matched controls. The cases were found to have lower birthweights for gestation (median standard deviation score of -1.02 in cases versus -0.08 in controls), and more frequently had pre-existing patent ductus arteriosus and intraventricular haemorrhage (88 and 63% in cases versus 25 and 6% in controls, respectively). There were similar rates of other perinatal variables in the two groups, including indomethacin and umbilical arterial catheter use. Conditions associated with fetal or neonatal hypoxia are important antecedents for this emerging distinct clinical entity.

Case-Control Studies↗
PubMed2006

New insights into spontaneous intestinal perforation using a national data set: (1) SIP is associated with early indomethacin exposure.

BACKGROUND: Spontaneous intestinal perforation (SIP) is increasingly common in the premature infant and is associated with significant morbidity. Indomethacin use has been implicated as a co-risk factor for SIP when combined with glucocorticoids, but previous evidence argued against indomethacin being an independent risk factor when used prophylactically. OBJECTIVES: (1) To establish a homogeneous cohort of SIP patients in a national data set and to contrast them to patients with surgical necrotizing enterocolitis (NEC). (2) To test the hypothesis that early post-natal indomethacin is independently associated with SIP. METHODS: A large de-identified data set was retrospectively queried by diagnosis, and then multiple antenatal and post-natal variables were tested by both univariate and multivariate analysis to identify associations with SIP. Sub-analyses were also performed to look at the timing of drug administration. RESULTS: There were 2105 patients evaluated in the data set. Patients were divided into matched controls (n = 581), those with SIP without report of NEC (n = 633) and those with NEC requiring surgery (n = 891). Infants with SIP were more likely to have a patent ductus arteriosus and more likely to be treated with vasopressors than either control or NEC patients. Compared to infants with NEC, patients with SIP were smaller, less mature and required more support. SIP was also diagnosed earlier than NEC (median of 7 vs 15 days). Patients with SIP were more likely to be treated with indomethacin, hydrocortisone or both on days of life 0-3 than controls. CONCLUSIONS: (1) Surgical NEC and SIP have significant differences in presentation, demographics and morbidity. (2) A detailed look at drug timing revealed that early post-natal indomethacin is independently associated with SIP.

Analysis of Variance↗
PubMedDate not supplied

Intestinal perforation in typhoid fever: a historical and state-of-the-art review.

The appropriate therapy for intestinal perforation in typhoid fever has been controversial since the late 1880s. Around the turn of the century, surgery became the established mode of therapy, with a mortality of 69% based on 166 patients in the English-language medical literature, and continued to be the preferred treatment until the advent of chloramphenicol in 1948. At this time the surgical mortality was approximately 50%. Following the recovery of a few patients with perforation treated only with antimicrobial agents (six initially, then eventually 22), nonsurgical therapy became the accepted mode of treatment. This change was never justified and this review demonstrates this. Appropriate therapy is virtually always surgical, usually consisting of simple closure and irrigation. Chloramphenicol alone is inadequate antimicrobial therapy in a patient with perforation and must be supplemented by other antimicrobials directed against enteric aerobic gram-negative bacilli and enteric anaerobes.

Anesthesia↗
PubMed1999

The mechanism of focal intestinal perforations in neonates with low birth weight.

Among 36 neonates with intestinal perforations (IP) between 1975 and 1996, 5 had necrotizing enterocolitis (NEC IP) and 10 had focal IPs (FIP). A histologic review of the bowel near the perforations was made to see if there was any difference between cases of NEC IP and FIP. In 1 case of NEC IP, a defect in the musculature was found in addition to disappearance of the mucosal villi and dilated vessels or hemorrhage in the submucosa. Thinning or absence of the intestinal musculature and short villi in the mucosa was observed in 3 cases of FIP, but the acute ischemic changes in FIP were much less than in NEC IP. Hypothesizing that the defective musculature in FIP may be acquired by a vascular accident either before or after birth, we examined the histology of the latest consecutive infants diagnosed as having meconium peritonitis (MP) due to in-utero volvulus and perforation. In the tissue near the perforation, there was an identical focus of thinning and interruption of the musculature while the acute ischemic changes were minimal. We speculate that thinning or absence of the intestinal musculature in FIP may be a result of a transient ischemic event occurring in-utero and that FIP may develop in the damaged intestine after birth when it is fully dilated.

Female↗
PubMed1993

[Intestinal perforation caused by severe electrical burn: report of 5 cases].

In recent 11 years, 5 cases of severe high voltage electrical burn with intestinal perforations were successfully treated. They showed obvious whole layer necrosis of abdominal wall, exudation, intestinal prolapse and peritonitis. On the basis of antishock therapy and protection of renal function, acute laparotomy was done early. Resection of the small intestine with necrosis and perforation and end-to-end anastomosis were done in 4 cases (5 regions). Colon resection and colostomy were done in 2 cases, and immediate end-to-end anastomosis in 2 cases. Bowel segment with external fistulae was left in 1 case (2 regions). If the abdominal wall defect could not be sutured directly, skin grafting on the residual tissue and omentum may be temporarily effective. And myocutaneous pedicle flap should be repaired secondarily. After operation, parenteral nutrition and anti-infection are important for patient recovery. No complication occurred in this group.

Adolescent↗
PubMed1990

[Toxic megacolon and intestinal perforation caused by Salmonella enteritidis].

Two cases of colitis due to Salmonella enteriditis which later developed a toxic megacolon with intestinal perforation are presented and the probable pathogenesis is discussed. This exceptional clinical course which has not been previously described forces to perform a differential diagnosis with chronic intestinal inflammatory disease which must be based on microbiologic, serologic and/or histologic criteria. Moreover, the authors warn about the unsuitability of using anticholigernic drugs in gastroenteritis since they could be related to the ethiopathogenical basis of the disease's unfavorable course in the described patients.

Adult↗
PubMed2004

Intestinal perforation after combined liver-kidney transplantation for a case of congenital polycystic disease.

AIM: To highlight the intestinal perforation (IP), an uncommon and catastrophic complication after combined liver-kidney transplantation. METHODS: Combined liver-kidney transplantation (LKTx) with left kidney excision and a cyst fenestration procedure on the right kidney were performed on a case of 46-year-old female with congenital polycystic disease (CPCD). RESULTS: Two sites of IP were noted 40-50 cm proximal to ileocecal area during emergent laparotomy 10 d postoperatively. Despite aggressive surgical and medical management, disease progressed toward a fatal outcome due to sepsis and multiple organ failure 11 d later. CONCLUSION: Long duration of operation without venovenous bypass, overdose of steroid together with postoperative volume excess may all contribute to the risk of idiopathic multiple IPs. Microbiology and pathology inspections suggested that the infected cyst of the fenestrated kidney might be one reason for the fatal intra-peritoneal infection. Thus for the CPCD patients who seem to be very susceptible to infectious complications, any sign of suspected renal-infection found before or during LKTx is indication for the excision of original kidney. And the intensity of immunosuppression therapy should be controlled cautiously.

Fatal Outcome↗
PubMed2006

[Intestinal perforation secondary to impaction of a retained endoscopic capsule].

We present the first documented case of intestinal perforation due to impaction of an endoscopic capsule. The capsule was used to investigate anemia in an 80-year-old woman and was retained in the intestinal lumen for 2 months without producing symptoms. The patient presented to the emergency service with sudden, intense, diffuse abdominal pain. Hollow viscus perforation was suspected and surgery was performed. The diagnosis was distal ileum perforation secondary to an impacted endoscopic capsule in an area of severe postsurgical adhesions under a subcostal cholecystectomy incision performed 10 years previously. After reviewing the literature, we believe it important to report this exceptional complication of capsule endoscopy and suggest the possible management of capsules retained in the digestive tract.

Aged, 80 and over↗
PubMed2001

Ascitic fluid carcinoembryonic antigen and alkaline phosphatase levels for the differentiation of primary from secondary bacterial peritonitis with intestinal perforation.

BACKGROUND/AIMS: In cirrhotic patients, spontaneous bacterial peritonitis (SBP) may be difficult to distinguish from secondary peritonitis with occult intestinal perforation; Runyon's criteria (based on ascitic fluid glucose, protein and lactate dehydrogenase levels) are sensitive but not specific. Ascitic fluid carcinoembryonic antigen (CEA) and alkaline phosphatase (AP) are potential markers for secondary peritonitis. METHODS: Ascitic fluid CEA and AP levels were prospectively compared among three subject groups--cirrhotic patients with sterile ascites, cirrhotic patients with SBP, and patients (cirrhotic and non-cirrhotic) with perforation-related secondary peritonitis. RESULTS: The secondary peritonitis group (n = 38 including 11 cirrhotic patients) had significantly higher mean CEA and AP levels than the SBP (n = 34) and sterile ascites patients (n = 63). Of secondary peritonitis patients, 92% fulfilled predetermined criteria (either CEA >5 ng/ml or AP >240 units/l) versus only 12% of SBP patients; sensitivity was 92% and specificity 88% for differentiating secondary peritonitis from SBP. Runyon's criteria had a sensitivity of 97% and specificity of 56%. Stratification of secondary peritonitis patients by the presence or absence of cirrhosis did not alter our results. CONCLUSIONS: Ascitic fluid CEA or AP elevations appear to be sensitive and specific markers for perforation-related secondary peritonitis in cirrhotic as well as non-cirrhotic patients.

Adult↗
PubMed2002

Spontaneous localized intestinal perforation in very-low-birth-weight infants: a distinct clinical entity different from necrotizing enterocolitis.

BACKGROUND: Idiopathic spontaneous intestinal perforation (SIP), a distinct clinical entity different from necrotizing enterocolitis (NEC), has an increasing prevalence in very-low-birth-weight infants. The aims of our study were to define patient characteristics and potential risk factors for premature infants with SIP compared with infants subjected to surgical treatment for NEC. STUDY DESIGN: The medical records of 29 premature infants with either SIP (n = 13) or NEC (n = 16) were reviewed retrospectively. RESULTS: Infants who experienced SIP were smaller at birth, had lower Apgar scores, and required more intensive neonatal resuscitation. An increased rate of premature rupture of membranes in infants with SIP (8/13 versus 6/16) was not associated with a higher rate of infection in mothers or infants. The onset of illness in SIP was significantly earlier than in NEC (p = 0.022). In contrast to patients with NEC (7/16), 11 of 13 patients in the SIP group had received indomethacin (p = 0.02). Bluish discoloration of the abdomen (8/13), a gasless abdomen (8/13), and the absence of pneumatosis intestinalis (0/13) were further significant markers in infants with SIP. At operation, SIP was always located in the terminal ileum in an antimesenteric position (13/13), and the remaining bowel appeared grossly normal. In most cases of SIP (10/13), the histologic investigation revealed an area of hemorrhagic necrosis without the typical coagulation necrosis seen predominantly in NEC. CONCLUSIONS: Based on clinical presentation and radiologic and intraoperative findings, SIP is a distinct pathologic entity in very-low-birth-weight infants and can be differentiated from classic NEC. Detected early, SIP can be treated by simple procedures (sutures, or resection and primary anastomosis) with a low rate of morbidity and mortality.

Chi-Square Distribution↗
PubMed2006

Concurrent use of indomethacin and dexamethasone increases the risk of spontaneous intestinal perforation in very low birth weight neonates.

BACKGROUND: Dexamethasone or indomethacin predisposes very low birth weight (VLBW) neonates to spontaneous intestinal perforation (SIP). However, no study has specifically investigated the role of the concurrent use of indomethacin and dexamethasone in SIP. OBJECTIVE: To test whether the concurrent use of indomethacin and dexamethasone increases the risk of SIP. METHODS: In this single center, retrospective, 2:1 matched, case-control study, the odds of SIP were assessed using univariate and multivariate logistic regression analysis in < or =14-day old VLBW infants. RESULTS: Sixteen VLBW infants with SIP were matched to 32 controls by birth weight. After adjusting for clinically relevant variables, patients who received > or =3 doses of indomethacin for ductal closure or intraventricular hemorrhage prophylaxis and > or =3 doses of low-dose dexamethasone (0.3 mg/kg cumulative dose over 3 days) for refractory hypotension during the first postnatal week, were 9.6 times more likely to develop SIP [95% CI 1.22, 75.71]. CONCLUSIONS: The combined use of indomethacin and dexamethasone increases the risk of SIP in VLBW neonates.

Case-Control Studies↗