Lactobacillus Peritonitis: A Rare Cause of Peritonitis in Peritoneal Dialysis Patients

Lactobacilli are part of the normal gastrointestinal and female genitourinary flora in humans and they are seldom pathogenic and rarely cause human disease. In the literature, Lactobacillus peritonitis was most common in immunocompromised patients, including patients under chronic peritoneal dialysis. We also suspect that the presence of Lactobacillus spp. in the peritoneal fluid might indicate the leakage of normal flora from a perforated intraabdominal hollow organ. To access the versatile clinical pictures of Lactobacillus peritonitis, this investigation retrospectively reviewed the medical records for Lactobacillus spp. isolated from peritoneal fluid from July 1998 to January 2002 at Chang‐Gung Memorial Hospital, Taipei, Taiwan. A total of 10 patients were enrolled in the study. Six of these 10 patients had concomitant intraabdominal hollow organ perforation, and peritoneal fluid cultures in these six patients also contained bacteria other than Lactobacillus spp. All six patients had recently experienced either abdominal surgery or blunt abdominal trauma. The remaining four patients who had not undergone surgery had decompensated liver cirrhosis with ascites and spontaneous bacterial peritonitis. The results suggested that the presence of Lactobacillus spp. in the peritoneal fluid other than immunocompromised patients should raise the suspicion of hollow organ perforation in patients with recent abdominal surgery or blunt abdominal trauma.     

Peritonitis: laparoscopic approach

Background  

Laparoscopy has became as the preferred surgical approach to a number of different diseases because it allows a correct diagnosis and treatment at the same time. In abdominal emergencies, both components of treatment – exploration to identify the causative pathology and performance of an appropriate operation – can often be accomplished via laparoscopy. There is still a debate of peritonitis as a contraindication to this kind of approach. Aim of the present work is to illustrate retrospectively the results of a case-control experience of laparoscopic vs. open surgery for abdominal peritonitis emergencies carried out at our institution.     

Peritonitis: laparoscopic approach

Background

Spontaneous rupture of the spleen is an uncommon dramatic abdominal emergency that requires immediate diagnosis and prompt surgical treatment to ensure the patients survival. Infections have been cited in most cases involving splenic rupture but are rare in hematological malignancies despite frequent involvement of the spleen.

Methods and Materials

We present a case of a splenic rupture caused by infiltration of B-cell lymphoma. A 43 year old gentleman presented with a 1 day h/o left upper quadrant pain; nausea and vomiting for 2 days with associated dizziness and anorexia. The CT showed abnormal spleen 20 × 11 cm with free fluid in the abdomen and enlarged retroperitoneal LNs. The patient underwent a splenectomy after initial resuscitation and the operative finding was that of a massively enlarged spleen with areas of tumor extruding through the splenic capsule.

Result and conclusion

Although the spleen is often involved in hematological malignancies, splenic rupture is an infrequent occurrence. In a recent literature review 136 cases were of splenic rupture secondary to hematological malignancy were identified. Acute leukemia and non Hodgkin lymphoma were the frequent causes followed by chronic myelogeneous leukemia. Male sex, adulthood, severe splenomegaly and cytoreductive chemotherapy were factors more often associated with splenic rupture. Emergency splenectomy remains the cornerstone treatment for splenic rupture. We present a case report of a "spontaneous splenic rupture" and discuss the presentation, etiology and treatment options along with discussion of relevant literature     

Acute diverticulitis: Surgical management

The management of acute diverticulitis is a constantly evolving field. Diverticular disease can range from mild abdominal pain to severe disease with perforation and sepsis. Due to this wide spectrum of presentation, management must be tailored to the individual. Treatment options vary from medical management to laparoscopic lavage to colectomy to appropriately treat the patient. The surgeon is responsible in assessing the necessity of surgery for patients who not only present acutely, but for those who have recovered and may need planning for possible recurrences. This chapter will review the current recommendations for the surgical management of acute diverticulitis.     

Peritonitis: Pathologic physiology involved in treatment

Peritonitis can usually be divided into an early formative or absorptive stage during which bacteriemia and bacterial toxemia preponderate, and the fully developed later stage in which circulatory disturbances and inhibition ileus preponderate.The most important factors that enter into the production of symptoms are: (a) bacteriemia and toxemia; (b) dehydration and demineralization; (c) reflex symptoms of nausea, anorexia and general depression; (d) inhibition ileus; (e) circulatory disturbances; (f) anoxemia, and (g) starvation.The most important local defensive factors against peritoneal infection are phagocytosis, formation of a fibrinous exudate and early localized intestinal inhibition. The general antibacterial activities are interfered with by anhydremia, demineralization, disturbances of the acidbase balance, anoxemia and circulatory disturbances.The surgical treatment involves the early removal of the focus of infection, with constant consideration of the importance of not disturbing the local defensive mechanisms.Dehydration and demineralization are treated by means of normal saline, Ringer's and Hartmann's solutions.The anoxemia is treated by correcting circulatory disturbances and by the early use of oxygen inhalations.To increase the colloid osmotic pressure of the plasma when a shock syndrome exists, 6 per cent acacia solution with minute doses of pitressin are to be used. (Suprarenal cortex extract may be of some value.)Fluids are not to be administered by mouth during any stage of peritonitis because they stimulate gut activity. However fluids may be given by mouth during the time that duodenal intubation with suction is applied.Proctoclysis and enemas are contraindicated in the early cases of peritonitis due to gangrenous appendicitis, when physiologic rest of the cecum is most desirable.Morphine is needed to control pain. It is doubtful whether deep morphinization has any specific beneficial effect in peritonitis and its deleterious effect upon the respiratory mechanism as well as upon the immune reactions must be borne in mind.The splanchnic vasomotor paralysis may be treated in the early stages only by means of small doses of ephedrine. Ephedrine also probably lessens “weeping” from the peritoneum and plasma loss into the intestine, and its inhibitory effect upon gut motility is of advantage during the early stages.Inhibition ileus and distention are treated by means of duodenal intubation and hypertonic salt solution intravenously. The stimulating effect of hypertonic salt solution upon propulsive intestinal motility contraindicates its use in the early formative stages.Glucose solutions are especially indicated during the starvation stage.Fowler's position is of definite value during the early, formative stages. Later the state of the circulation and the patient's comfort should determine the position of the patient.Mild x-ray treatment during the early formative stages of peritonitis is probably indicated because it raises the antibacterial defense mechanisms.The possibility of a mechanical obstruction occurring in peritonitis, from kinking of the bowel, localized abscess, or from a plastic exudate is to be borne in mind. Enterostomy is indicated only after the simple method of duodenal intubation with suction has been given a trial.Spinal anesthesia is contraindicated during the early absorptive stages of peritonitis because of its stimulating effect upon peristalsis. Ether is contraindicated during any stage of peritonitis.The inefficacy of drainage in general peritonitis cases is briefly discussed.     

Pylephlebitis in the course of diverticulitis

Pylephlebitis or septic portal thrombophlebitis is a rare but serious condition which may occur following intra-abdominal sepsis from any source. Sigmoid diverticulitis is one of the most common sources. Modern imaging modalities, particularly CT, have increased the recognition of this condition. Standard treatment consists of anticoagulation plus antibiotic therapy to cover anaerobic and gram negative organisms. The duration of anticoagulation therapy remains controversial. Sigmoid colectomy may be required in cases of perforated diverticulitis or failure of medical therapy.     

Surgical diverticulitis: treatment options.

Acute diverticulitis requiring surgical intervention has conventionally been treated by resection with colostomy or delayed resection with primary anastomosis at a second admission. Our objective was to determine the outcome for treatment of diverticulitis with resection and primary anastomosis during the same hospitalization. We conducted a retrospective review of patients (n = 74) undergoing surgery for diverticulitis. Groups included: 1) resection with primary anastomosis (n = 33), 2) resection with colostomy followed by a takedown colostomy (n = 32), and 3) delayed resection with primary anastomosis at a second admission (n = 9). Despite local perforation primary anastomosis was often performed unless patients were clinically unstable or had fecal contamination. The operation was urgent in five (15%) patients in Group 1 as compared with 26 patients (88%) in Group 2. Serious intra-abdominal complications occurred in two patients (6%) in Group 1 as compared with nine patients (28%) in Group 2 and one patient (11%) in Group 3. Postoperative abscesses occurred in two patients in Group 1, five patients in Group 2, and one patient in Group 3. We have shown that resection with primary anastomosis for acute diverticulitis--even in selected patients requiring urgent operation--can be safely performed during the same hospital admission with a low complication rate.     

Cecal diverticulitis: a diagnostic challenge

BACKGROUND: Cecal diverticulitis is frequently indistinguishable from acute appendicitis preoperatively and is sometimes mistaken for carcinoma at laparotomy. The surgeon must be aware of the possibility of diverticulitis of the cecum in the operating room and choose the appropriate treatment. PURPOSE: Because there is no universal therapeutic approach to these patients, we decided to assess the presenting symptoms, clinical findings, preoperative diagnosis, operative findings determining the proper management of these patients. METHODS: A retrospective chart review of 13 patients with pathologically confirmed cecal diverticulitis, who underwent surgery in our department from 1984 to 1998, was undertaken. RESULTS: The mean age of patients was 43.5 years. Right lower quadrant pain and local tenderness were the only clinical findings in 92.3%, with preoperative diagnosis of acute appendicitis in 84.6% of patients. The operative finding in most cases was inflammatory mass of the cecum; in 6 cases it was indistinguishable from perforated cecal carcinoma. Six patients underwent right hemicolectomy, 5 had ileocecectomy, 1 patient was treated by tube cecostomy, and 1 had diverticulectomy. There were three minor postoperative complications: pneumonia, wound infection and lower limb superficial thrombophlebitis. CONCLUSIONS: Cecal diverticulitis needs a high index of suspicion for achieving a preoperative diagnosis. We suggest that the operative therapy should be ileocecectomy. The surgical specimen should be examined during surgery and only if carcinoma is found should the patient have a formal colectomy.     

Changes in the approach to acute diverticulitis

Acute diverticulitis (AD) is one of the most common acute admission diagnoses for general surgery, and its prevalence is increasing, in part due to the ageing population. Currently, most patients who present to a tertiary hospital are admitted for a period of treatment and observation. Simple, safe and cost‐effective strategies for improving our current treatment of this condition will be invaluable in providing the most appropriate management for individual patients and for reducing the health resources expended on hospital admissions and parenteral antibiotics. AD can be categorized as uncomplicated or complicated, these two subtypes have a very different clinical course. The management of uncomplicated AD has become increasingly conservative, with a focus on symptomatic relief and supportive management. Recent research has brought into question the need for extended hospital admission and questioned the current use of antibiotics. Anti‐inflammatory agents that reduce local inflammation in uncomplicated AD may be a useful means of reducing damage caused by inflammation and aiding earlier resolution of the inflammatory response and associated symptoms. Mesalazine is an anti‐inflammatory agent that has been trialled in uncomplicated AD. Mesalazine has been shown to improve time to resolution of endoscopic and histological evidence of inflammation following an episode of AD and also reduce the rate of recurrence. In this literature review, we provide an overview of recent advances in AD classification, pathophysiology and management, and examine the possibility of introducing the use of anti‐inflammatory agents in the management of uncomplicated AD.