Download General Data Chief Complaint History of Present Illness

General Data
A Case Presentation and
Discussion on Peritoneal
Irritation
D.A., 29 y/o, male,
from Paranaque City
By:
Roderick S. Mujer MD
Surgery Resident
Ospital Ng Maynila Medical Center
History of Present Illness
Chief Complaint
7 days PTA
moderate to high grade Fever
Abdominal pain
1 day PTA
Hypogastric pain with diarrhea
and body malaise
Few hours PTA
inc severity of abdominal pain
becoming generalized
Consulted at FM-ER
1
History of Present Illness
Past Medical History
• Unremarkable
X- RAY Upright
Pneumoperitoneum
Personal and Social History
• Smoker 5 pack years
Referred to Surgery
Physical Examination
Conscious, coherent, NICRD
BP= 100/60
HR =85
RR =25
T° =39°
HEENT: Pink palpebral conjunctiva, anicteric sclerae
Chest & Lungs:
symmetrical chest expansion
harsh equal breath sounds
Heart: Normal rate, regular rhythm
Physical Examination
Abdomen
distended
hypoactive bowel sounds
(+) direct tenderness all over
(+) muscle guarding
(+) rigidity
Rectal
good sphincteric tone, Full rectal vault
(+) mucoid feces on tactating finger
2
29 y,o, male
Sudden onset of abdominal
pain
Salient Features
•
•
•
•
•
•
•
29 y.o, male
Prolonged Fever
Hypogatric pain and diarrhea
Abdominal distension
(+) tenderness all over
(+) muscle guarding & rigidity
(+) pneumoperitoneum
NON- SURGICAL ABDOMEN
SURGICAL ABDOMEN
tenderness all over
(+) muscle guarding & rigidity
Pneumoperitoneum
Perforation
Prolonged
Fever
Typhoidal
Non Typhoidal
PUD
Appendix
Vascular
Pretreatment Diagnosis
CONDITION
CERTAINTY
Paraclinical diagnostic
procedure
TREATMENT
• Do I Need A Paraclinical Diagnostic Procedure?
PRIMARY
SECONDARY
Acute Surgical
Abdomen
2ndry to a
perforated
typhoid ileitis
Acute surgical
abdomen 2ndry
to a perforated
Viscus
95%
surgical
5%
surgical
No.
3
Treatment Options
Goal of treatment
A. Resolve the underlying cause
B. Restore bowel continuity
C. Least morbidity and mortality
BENEFITS
OPTIONS
Primary Repair
A
+++
B
RISK
RR
COST
AVAILABILI
TY
C
MB
MR
++++
46%
6.5%
+
+
+
14%
Ileostomy
+++
+
52%
+
++++
+
Resection
Anastomosis
+++
++
50%
30%
+
+++
+
Repair with Ileotransverse
Bypass
+++
++
50%
21%
+
+++
+
Beniwal U, Jindal D, Sharma J, Jain S, Shyam G. Comparative study of
operative procedures in typhoid perforation. Indian J Surg 2003;65:172-177
Pre- Operative Preparation
Give psychosocial support
Secure Consent
Optimize condition of patient
Nasogastric tube and foley catheter placed
Fluid resuscitation and hydration
Pre-op monitoring
Antibiotics
Screening of other condition that will
interfere with treatment
Operative Technique
•
•
•
•
•
Patient supine
Asepsis antisepsis
Sterile drapes placed
Midline incision carried down to the peritoneum
Intraop findings noted
Prepare materials
4
Operative Findings
(+) single 7mm
perforation noted
40cm from ileocecal
junction
(+) greenish ileal
contents
(+) generalized
peritonitis
Operation
Exploratory Laparotomy
Primary Repair of Ileum
Operative Technique
• Primary repair of bowel injury using silk 4-0
• Simple interrupted sutures, 2nd layer with lembert
sutures
• Hemostasis assured
• Peritoneal lavage done
• Instrument, needles and sponge checked
• Layer by layer closure
• Partial skin closure
• Wound lightly dressed
Final Diagnosis
Generalized Peritonitis 2ndry to a
Perforated Typhoid Ileitis
5
Post-op Care
1st POD
NGT maintained
Hydration continued
IV Antibiotics
3rd POD
Catheter removed
NGT removed
5th POD
IVF consumed
Diet as tolerated
Shifted to oral meds
6th POD
•
•
• Follow up after 1 week
• Oral medications for 2 weeks
• Educate patient for proper handling of food
and waste dispossal
Discharged
Discussion
•
Follow-up
Typhoid fever is an endemic disease in tropical
countries
Common in males than in females with a ratio
of 6:1
Common presentation includes:
- prolonged fever
- sudden onset of abdominal pain
- abdominal distension
- constipation
- diarrhoea
- vomiting
Discussion
• Infection is caused by Salmonella Typhi
• Acquired through ingestion of contaminated
food and water with excreta from a patient
with typhoid or from a convalescing or
chronic carrier
• Incubation period of about 10 to 14 days.
6
Discussion
• The diagnosis is often strongly suggested
by the clinical presentation
• Blood cultures are 80% sensitive during
the first 2 weeks of the illness;
Discussion
• Bone marrow culture is the single most effective
90% sensitive and remains positive even when
the blood cultures have become negative due to
antibiotic therapy.
• A rising titre of agglutinin (the Widal test for
antibodies against the flagella (H) and somatic
(O) antigen) over a week, especially when
cultures are negative.
Discussion
• Stool and urine cultures become positive
from the second week on in patients who
have not been treated.
• By the third week blood cultures are often
negative, as the organisms are now mainly
intracellular.
Discussion
• Ingestion the bacilli-- intestinal mucosa--spread
via the lymphatics and blood stream-- RES
• Re-entry of typhoid bacilli into the bloodstream
marks the onset of clinical typhoid fever
• Second or third week of the illness heavy
reinfection of the gut
• The bacilli localize in the Peyer's patches in the
lower ileum.
7
Discussion
Discussion
• Necrosis of Peyer's patches with
ulceration of the intestinal mucosa occurs
in the long axis of the bowel
• Most of the perforation(s) was/were
located in the terminal ileum within 2 feet
of the ileocaecal junction
• Intestinal haemorrhage or perforation of
the bowel with resultant peritonitis may
occur.
• Single perforation is the most common
Discussion
• Operative treatment is preferred because
typhoid perforation produces fulminating
peritonitis and, unlike other perforations,
rarely seals up as the omentum seldom
migrates to the area of perforation
• Perforation occurred mostly in the first
and second week of fever
Discussion
Major complications
• wound infection
• fecal fistula
• wound dehiscence
• bleeding diathesis
• skin excoriation around ileostomy
8
Discussion
• Mortality was more in patients with
multiple perforations as compared to
single perforation cases
• Factors significantly affecting mortality
were number of perforations and the
development of fecal fistula
Discussion
• Chloramphenicol - drugs of choice
adult: 500 mg q4 till fever subsides, then 500 mg q6 for
14 days
children: 50 mg/kg.day in divided doses for 21 days
• Amoxycillin
adult: 1 g 6-hourly orally for 14 days;
children 100 mg/kg.day in divided doses for 21 days
• Cotrimoxazole
adult: 800 mg 12-hourly orally for 14 days
children: 6 mg trimethoprim plus 30 mg
sulphamethoxazole/kg/day for 14 days
Discussion
Prevention
• Ciprofloxacin - drug of choice for the
treatment of infection with multiresistant S.
typhi.
• 500 mg q12 for 14 days
Primary
Reduction or elimination of a disease by
measures intended to prevent or avoid onset of
the disease
• Oral typhoid vaccines prophylaxis
9
Prevention
Prevention
Secondary
Tertiary
Reduction or elimination of a disease by
interventions in asymptomatic and at risk
individuals identified prior to development of
clinical manifestations of disease.
Reduction or elimination of a disease by
interventions (commonly referred to as
treatment) in symptomatic individuals identified
after development of clinical manifestations of
disease
• Eradication in endemic areas requires by
providing safe water supplies and waste
disposal.
• Health education on proper ways of cooking and
storing food
References
1.
Beniwal U, Jindal D, Sharma J, Jain S, Shyam G. Comparative
study of operative procedures in typhoid perforation. Indian J
Surg 2003;65:172-177
2.
Dofitas RB, Crisosotomo AC, Roxas AB. Prospective clinicopathologic comparison between typhoid and non- typhoid
ileal perforations. Philipp J Surg Spec 1994; 49(1):31-35
3.
4.
Adensunkanni AR, Desunkan MI, Ajao OG. The prognostic
factors in typhoid ileal perforation: A prospective study of 50
patients. J R Coll Surg Edinb 1997;42:395-9.
Athie CG, Guizar CB, Alcantara AV, Alcaraz GH, Montalvo EJ.
Twenty-five years of experience in the surgical treatment of
perforation of the ileum caused by Salmonella typhi at the
general hospital of Mexico City. Surgery 1998:123:632-6.
References
5.
Talwar S, Sharma RK, Mittal DK, Prasad P. Typhoid enteric
perforation. Aust N Z J Surg 1997;67:351-3
6.
Eggleston FC, Santoshi B. Typhoid perforation: Choice of
operation. Br J Surg 1981;68:341-2. [PUBMED]
7.
Singh KP, Singh K, Kohli JS. Choice of surgical procedure in
typhoid perforation: Experience in 42 cases. J Indian Med
Assoc 1991;89:2556. [PUBMED
8.
Botongbacal JJ, Roxas AB. Typhoid perforation of the bowel:
Operative experience with 64 cases. Philipp J Surg Spec
1993; 48(4):165-168
10
Questions
Questions
1. What is the drug of choice for
multiresistant Salmonella Typhi infection?
2. What is the most common presenting
symptoms of S. Typhi infection?
a.
b.
c.
d.
a.
b.
c.
d.
Chloramphenicol
Ampicillin
Ciprofloxacin
Metronidazole
Abdominal pain
Prolonged fever
Anorexia
Diarrhea
Questions- MCR
Questions
3. Which of the following is/are reliable
diagnostic modalities in Typhoid Fever of
three weeks duration of illness?
4. The following are factors that significantly
affects the mortality in typhoid perforation
except?
1.
2.
3.
4.
1.
2.
3.
4.
Stool culture
Bone marrow culture
Typhi dot test
Blood culture
Number of perforations
Development of fecal fistula
Duration of perforation
Development of surgical site infection
11
Questions
5. The following organ system may be
involve in Salmonella infection except?
1.
2.
3.
4.
Cardiovascular
Skeletal
Integumentary
Adrenal
12