Idiopathic Colonic Perforation in Adult—A Rare Case

Idiopathic perforation of normal colon in adults is rare. The cause for idiopathic perforation is not known. We report a case of idiopathic colonic perforation in adult who presented with sign and symptoms of perforative peritonitis. On laparotomy patient was diagnosed to have a colonic perforation. There was no causative factor for perforation in the patient. This case is reported because of rarity of this disease     

Laparoscopic repair of perforated peptic ulcer: single-center results

Background

Perforated peptic ulcer (PPU), the most common indication for emergency gastric surgery, is associated with high morbidity and mortality rates. Outcomes might be improved by performing this procedure laparoscopically, but no consensus exists on whether the benefits of laparoscopic repair (LR) of PPU outweigh the disadvantages.

Methods

From January 2002 to December 2012, 111 patients underwent surgery for perforated ulcer. A “laparoscopy-first” policy was attempted and then applied for 56 patients. The exclusion criteria for LR ruled out patients who had shock at admission, severe cardiorespiratory comorbidities, or a history of supramesocolic surgery. The aim of this study was a retrospective analysis of the 56 patients treated laparoscopically.

Results

The patient distribution was 30 men and 26 women, who had a mean age of 59 years (range 19–95 years). The mean ulcer size was 10 mm, and the Mannheim peritonitis index (MPI) was 21. LR was performed for 39 (69.6 %) of the 56 patients and included peritoneal lavage, suturing of the perforation, and omental patching. Conversion to laparotomy was necessary in 17 cases (30.4 %). The “conversion group” showed significant differences in ulcer size (larger ulcers: 1.9 vs 0.7 mm; p < 0.01), ulcer-site topography (higher incidence of posterior ulcers: 5 vs 0; p < 0.01), and MPI score (higher score: 24 vs 20; p < 0.05). The LR group had a mean operating time of 86 min (range 50–125 min), an in-hospital morbidity rate of 7.6 %, a mortality rate of 2.5 %, and a mean hospital stay of 6.7 days (range 5–12 days). None of these patients required reintervention.

Conclusions

The results showed that LR for PPU is feasible with acceptable mortality and morbidity rates. Skill in laparoscopic abdominal emergencies is required. Perforations 1.5 cm or larger, posterior duodenal ulcers, and an MPI higher than 25 should be considered the main risk factors for conversion.     

Pneumoperitoneum complicating mechanical ventilator therapy.

Subdiaphragmatic air arouses the clinical suspicion of a perforated intra-abdominal viscus. In patients with respiratory failure requiring mechanical ventilation, the retroperitoneal dissection of air from the mediastinum may give rise to radiologic evidence of subdiaphragmatic emphysema. The present report describes four patients with this syndrome. In three of them, a perforated gastric or duodenal ulcer was initially suspected. None of these three patients underwent surgery. Autopsy examinations in two patients revealed extraperitoneal subdiaphragmatic emphysema with secondary rupture into the free peritoneal cavity. The third patient had an uneventful recovery and was discharged from the hospital. In a fourth patient, signs of peritonitis prompted an exploratory laparotomy. No perforation of an intraperitoneal viscus was identified. Upper gastrointestinal contrast roentgenography and peritoneal lavage may help determine the etiology of subdiaphragmatic air in patients undergoing therapy with a mechanical ventilator.     

An unusual presentation of spontaneous pneumoperitoneum secondary to the rupture of a gas-containing pyogenic liver abscess: Report of a case

We describe a rare case of spontaneous pneumoperitoneum secondary to the rupture of a gas-containing pyogenic liver abscess in a 59-year-old man. The patient was diagnosed as having a hollow viscus perforation based on a sudden onset of acute abdominal pain along with radiological evidence of bilateral subphrenic feee air (pneumoperitoneum), and underwent an emergency laparotomy. Contrary to expectations, the surgery revealed no perforations of the hollow viscus, but instead a ruptured liver abscess at the dome of the right hepatic lobe was identified associated with suppurative peritonitis. To the best of our knowledge, such a case of spontaneous pneumoperitoneum secondary to the rupture of a gas-containing liver abscess is extremely rare.     

Perforated peptic ulcer-an update

Peptic ulcer disease(PUD) affects 4 million people worldwide annually. The incidence of PUD has been estimated at around 1.5% to 3%. Perforated peptic ulcer(PPU) is a serious complication of PUD and patients with PPU often present with acute abdomen that carries high risk for morbidity and mortality. The lifetime prevalence of perforation in patients with PUD is about 5%. PPU carries a mortality ranging from 1.3% to 20%. Thirtyday mortality rate reaching 20% and 90-d mortality rate of up to 30% have been reported. In this review we have summarized the current evidence on PPU to update readers. This literature review includes the most updated information such as common causes, clinical features, diagnostic methods, non-operative and operative management, post-operative complications and different scoring systems of PPU. With the advancement of medical technology, PUD can now be treated with medications instead of elective surgery. The classic triad of sudden onset of abdominal pain, tachycardia and abdominal rigidity is the hallmark of PPU. Erect chest radiograph may miss 15% of cases with air under the diaphragm in patients with bowel perforation. Early diagnosis, prompt resuscitation and urgent surgical intervention are essential to improve outcomes. Exploratory laparotomy and omental patch repair remains the gold standard. Laparoscopic surgery should be considered when expertise is available. Gastrectomy is recommended in patients with large or malignant ulcer.     

Conservative management of idiopathic pneumoperitoneum masquerading as peritonitis: Report of a case

Pneumoperitoneum is most commonly caused by the perforation of a hollow viscus, in which case an emergency laparotomy is indicated. We report herein the case of a patient who, presented with the signs and symptoms of peritonitis, but who was found to have idiopathic pneumoperitoneum which was successfully managed by conservative treatment. A 70-year-old man presented with epigastric pain, nausea, and a severely distended and tympanitic abdomen. Abdominal examination revealed diffuse tenderness with guarding, but no rebound tenderness. He was febrile with leukocytosis and high C-reactive protein. Chest X-ray and abdominal computed tomography demonstrated a massive pneumoperitoneum without pneumothorax, pneumomediastinum, pneumortroperitoneum, or subcutaneous emphysema, and subsequent examinations failed to demonstrate perforation of a hollow viscus. Thus, a diagnosis of idiopathic pneumoperitoneum was made, and the patient was managed conservatively, which resulted in a successful outcome. This experience and a review of the literature suggest that idiopathic pneumoperitoneum is amenable to conservative management, even when the signs and symptoms of peritonitis are present.     

Spontaneous pneumoperitoneum. A surgical dilemma

Pneumoperitoneum is usually the result of hollow viscus perforation with associated peritonitis. Nonsurgical spontaneous pneumoperitoneum incidental to intrathoracic, intra-abdominal, gynecologic, iatrogenic, and other miscellaneous causes not associated with perforated viscus have been documented in the literature. Seven cases of spontaneous pneumoperitoneum admitted over 3-year period to Grady Memorial Hospital, Atlanta, Georgia are reported. Six patients with pneumoperitoneum underwent exploratory laparotomy when clinical examination suggested an acute abdomen; no intra-abdominal pathology was documented in any of these patients. A seventh patient, on ventilatory support, was managed conservatively after performing a diagnostic peritoneal lavage that was negative. There were no cases of radiographically misdiagnosed pneumoperitoneum. Pneumoperitoneum, preceded by a reasonable incidental cause in a patient with a adequate abdominal examination, may warrant continued observation thus avoiding an unnecessary laparotomy.     

Pneumoperitoneum in a patient with pneumothorax and blunt neck trauma

INTRODUCTION

Blunt trauma as a cause of pneumoperitoneum is less frequent and its occurrence without a ruptured viscus is rarely seen.

PRESENTATION OF CASE

We report a case of blunt neck trauma in which a motorcycle rider hit a fixed object causing severe laryngotracheal injury. The patient developed pneumothorax bilaterally and had pneumoperitoneum despite no injury to the internal viscus. Bilateral chest tube drainage and abdominal exploratory laparotomy was performed.

CONCLUSION

Free air in the abdomen after blunt traumatic neck injury is very rare. If pneumoperitoneum is suspected in the presence of pneumothorax, exploratory laparotomy should be performed to rule out intraabdominal injury. As, there is no consensus for this plan yet, further prospective studies are warrant. Conservative management for pneumoperitoneum in the absence of viscus perforation is still a safe option in carefully selected cases.     

Pneumoperitoneum and its association with ruptured abdominal viscus

Pneumoperitoneum is not invariably associated with ruptured or perforated intra-abdominal viscus. To determine the incidence of free air associated with intra-abdominal viscus perforation, the medical records of 77 consecutive patients whose discharge or autopsy diagnosis included pneumoperitoneum or perforated viscus at a community hospital were retrospectively reviewed between June 1980 and October 1985. Abdominal viscus perforation, as determined by contrast studies or at operation, was not invariably associated with free air. Sixty-nine percent (23/33) of gastroduodenal, 30% (3/10) of small-bowel, and 37% (11/30) of large-bowel perforations had free air, as determined by preoperative x-ray film. Four cases with a total of six episodes of pneumoperitoneum were identified where viscus perforation was not documented. Pneumoperitoneum thus remains a reliable sign of viscus perforation; however, lack of this finding does not rule out perforation, and unusual causes must be considered.     

Unusual pneumoperitoneum secondary to ruptured liver abscess-A case report

IntroductionPyogenic liver abscess is important cause of hospitalization and life threatening disease in low-middle income countries. Clinical spectrum of ruptured GFPLA can mimic hollow viscus perforation as it usually accompanied by pneumoperitoneum and peritonitis.Case presentationWe reported here a case with pneumoperitoneum caused by ruptured liver abscess in a 27-year-old man with a history of uncontrolled type II diabetes mellitus. He had an abdominal pain, distension of abdomen associated with a high fever. Patient was diagnosed peritonitis and pneumoperitoneum presumed to be secondary to perforation of a hollow viscus and subjected to emergency laparotomy. We did not find any gastrointestinal perforation. Surprisingly, we detected a ruptured liver abscess in the right lobe of the liver.. The patient was in septic shock and hence shifted to ICU with inotropic support. Antibiotic therapy was started according to pus culture sensitivity. Even with the above treatment patient was not improved and on 4th postoperative day the patient collapsed and declared dead.DiscussionPneumoperitoneum secondary to ruptured gas containing pyogenic liver abscess is rare and could represent as life threatening infection. It should be distinguished from perforation of hollow organ by clinical symptoms and image examinations, particularly like CT. Accurate diagnosis with adequate drainage and antibiotic therapy would bring good outcome.ConclusionWe are aware that not every case of pneumoperitoneum is attributable to a perforated hollow viscus. A rapid and prompt surgical intervention with appropriate antibiotics are essential to save a life.     

Spontaneous pneumoperitoneum without peritonitis.

Spontaneous pneumoperitoneum without peritonitis is a rare phenomenon which poses a dilemma to the surgeon faced with this problem. Two such cases and their outcome are presented. The first case was caused by barotrauma during positive pressure ventilation and was treated by laparotomy. No perforated viscus was found. The second case was caused by tracheal rupture during emergency intubation and was treated by observation until complete resolution. Both patients died for reasons unrelated to the pneumoperitoneum. The mechanisms for passage of air from the chest into the abdominal cavity were through the diaphragm in the first case and along the great vessels in the second. A compilation of other etiologies of pneumoperitoneum without peritonitis as extracted from the literature is presented. In the presence of pneumoperitoneum without peritonitis and when the clinical history does not suggest perforation of a viscus, we advise performing an abdominal tap. If negative, continued observation is advised.     

Abdominal visceral perforation by buried peritoneal dialysis catheters: Cause or coincidence?

Delayed visceral organ perforations after PD catheter insertions are extremely rare. We report two patients who presented with asymptomatic visceral perforation from their buried PD catheters. Five months after a laparoscopic buried PD catheter insertion in a 92‐year‐old man PD was initiated; bile and bowel contents were noted in the PD effluent. He subsequently expired (from pneumonia) to autopsy revealed the PD catheter within the small bowel. Despite this perforation, there was no evidence of peritonitis, inflammation, nor any bowel content within the peritoneal cavity. A second case was observed 2.5 months after an uncomplicated laparoscopic buried PD catheter insertion in a 60‐year‐old woman. PD was attempted; the patient had an immediate urge to void. MRI revealed the presence of the PD catheter within her bladder. She underwent PD catheter revision the next day with repair of bladder perforation and ultimately successfully initiated PD . Since the perforations did not occur at the time of catheter placement, we believe that the catheter eroded into a viscus, perhaps related to the lack of a fluid at the catheter ‐ viscus interface. The diagnosis of delayed visceral organ perforation following buried PD catheter insertion may be delayed because the catheter is not immediately used.     

Spontaneously perforated pyometra presenting as diffuse peritonitis: Report of a case

We report herein a rare case of spontaneously perforated pyometra found in a 72-year-old woman who was admitted to our hospital with abdominal pain and vomiting. A distended abdomen with muscular rigidity, a positive Blumberg sign, and a WBC count of 11,900/mm³ indicated diffuse peritonitis, although a plain abdominal X-ray film revealed no free air in the peritoneal cavity. An emergency laparotomy was performed, which revealed a lot of pus, and perforation in the fundus of a distended uterus. The patient was therefore diagnosed as having suffered uterine perforation associating with a pyometra, and a total hysterectomy with bilateral salpingo-oophorectomy was carried out. Histological examination revealed a pyometra with inflammation and destruction of the endometrium and myometrium, and cervical occlusion with no evidence of malignancy. Postoperatively, the patient developed a subcutaneous abscess and pneumonia, but recovered and was discharged on the 74th day after her operation. Thus, although rare, spontaneously perforated pyometra should be considered when elderly women present with acute abdominal symptoms.     

Lupus peritonitis mimicking acute surgical abdomen in a patient with systemic lupus erythematosus: Report of a case

A 25-year-old Japanese woman who had been suffering from systemic lupus erythematosus (SLE) for 12 years was admitted to our hospital with a suspected diagnosis of peritonitis after suddenly developing severe abdominal pain and distention which could not be relieved by treatment with anodyne. Noninvasive examinations did not provide enough evidence to rule out acute appendicitis, bowel performation, or ischemia due to vasculitis. Therefore, in consideration of the severity of her uncontrollable abdominal pain, an exploratory laparotomy was performed. The operative findings revealed nonbacterial peritonitis with a large amount of ascites and an edematous small bowel. No perforation of the intestine was found. On post-operative day (POD) 3, the severe abdominal pain redeveloped, but responded well to steroid pulse therapy. Based on the operative findings and her clinical course, the most likely diagnosis was thought to be acute lupus peritonitis. It is often difficult to ascertain whether abdominal pain in an SLE patient is due to lupus peritonitis or to an underlying cause requiring surgery. Thus, it is essential that continuous and careful assessment of the surgical abdomen is performed when a patient with SLE develops acute abdominal pain, and if a surgical condition cannot be ruled out, a laparotomy should be performed without delay.     

A case of perforative peritonitis caused by a piece of bamboo in a patient on peritoneal dialysis

We report a case of peritonitis resulting from colon perforation caused by ingestion of a rare foreign body in a patient on peritoneal dialysis (PD). A 72-year-old woman on PD was hospitalized with abdominal pain and cloudy PD fluid (PDF). Although conventional antibiotic therapy was started because of a diagnosis of infectious peritonitis, low-grade fever, abdominal pain and a high number of white blood cells in PDF persisted. On day 3, anaerobic bacteria were recognized on bacterial culture of PDF, suggesting a gastrointestinal etiology. During exploratory laparotomy, sigmoidal perforation by a piece of bamboo, probably resulting from ingestion of contaminated food, was found.     

The acute abdomen in patients with ventriculoperitoneal shunts.

A rationale for management of the patient with an acute adbomen and a ventriculoperitoneal shunt is presented in relation to eight patients. In two patients peritonitis was due to perforation of an abdominal viscus, not shunt related, and six were due to infections of ventriculoperitoneal shunts. Resolution of abdominal symptomatology occurs within six hours after the distal end of the shunt catheter is removed from the abdomen and placed in a drainage bottle. In four of these six, infection was limited to the peritoneal end of the catheter. The ventricular fluid was sterile.     

Jejunal gastric heterotopia presenting as perforation peritonitis in a middle-aged adult: A case report

IntroductionGastric heterotopia rarely occurs in the small intestine beyond ligament of Treitz. Most cases of jejunal gastric heterotopia have been reported in children and young adults. Herein we report a case of jejunal gastric heterotopia presenting as a perforation peritonitis in a middle-aged adult.Presentation of caseA 51-year-old male presented with abrupt onset abdominal pain of 1 day duration. Physical examination revealed abdominal tenderness and rebound tenderness as well as costovertebral angle tenderness. Abdominal computed tomography revealed pneumoperitoneum, suggestive of hollow viscus perforation. At emergency laparotomy, a perforation site was discovered in the jejunum 100 cm distal to the ligament of Treitz. On macroscopic examination, the mucosa contained a 3 × 4 cm ill-defined, shallow ulceration next to the perforation site. Microscopically, the mucosa surrounding the perforation site revealed gastric heterotopia which consisted of gastric foveolar epithelium along with abundant pyloric glands and a few fundic glands.DiscussionTo the best of our knowledge, this case is the presumed oldest jejunal gastric heterotopia patient presenting with perforation peritonitis ever reported.ConclusionJejunal gastric heterotopia should also be considered in the differential diagnosis of perforation peritonitis in adults.     

Uncommon cause of pneumoperitoneum

Free intraperitoneal air is thought to be pathognomonic for perforation of a hollow viscus. Here, we present a patient with pain in the upper left quadrant, a mild fever and leukocytosis. Free air was suggested under the left diaphragm but during the explorative laparotomy no signs of gastric or diverticular perforation were seen. Further exploration and revision of the computed tomography revealed a perforated splenic abscess. Splenic abscesses are a rare clinical entity. Presenting symptoms are often non-specific and include upper abdominal pain, recurrent or persistent fever, nausea and vomiting, splenomegaly, leukocytosis and left lower chest abnormalities. Predisposing conditions can be very divergent and include depressed immunosuppressed state, metastatic or contiguous infection, splenic infarction and trauma. Splenic abscess should therefore be considered in a patient with fever, left upper abdominal pain and leukocytosis. Moreover, our case shows that splenic abscess can present in an exceptional way without clear underlying aetiology and should even be considered in the presence of free abdominal air.     

Pneumoperitoneum: is exploratory laparotomy always indicated?

Pneumoperitoneum usually indicates a surgical emergency because of visceral perforation in 85 to 95% of cases. Spontaneous pneumoperitoneum without peritonitis is a rare phenomenon which poses a dilemma for the surgeon who is faced with this problem. Some cases of pneumoperitoneum can and should be managed conservatively. We report three cases of pneumoperitoneum and describe their outcomes. Two cases were treated conservatively, and one underwent laparotomy but no perforated viscus was found. We review the aetiological mechanisms and the pathophysiology of the appearance of intra-abdominal free gas. Furthermore, a compilation of other aetiologies of pneumoperitoneum without peritonitis as reported in the literature is presented. Pneumoperitoneum, preceded by a reasonable clinical history in a patient with an adequate abdominal examination, may warrant continued observation, thus avoiding an unnecessary laparotomy.