Analysis of the clinical diagnosis and treatment of fetal meconium peritonitis

BACKGROUND

The purpose of this study was to improve diagnostic and therapeutic standards by examining the clinical features, treatment, and prognosis of fetal meconium peritonitis (FMP), as well as the diagnostic efficacy of ultrasound for FMP.

METHODS

The clinical data of 41 infants and pregnant women diagnosed with meconium peritonitis (MP) and treated at the Fujian Maternal and Child Health Hospital from January 2013 to January 2020 were analyzed retrospectively. Clinical data, imaging data, complications, treatment strategies, pregnancy outcomes, neonatal prognoses, and follow-up outcomes were all analyzed.

RESULTS

The MP prenatal diagnosis rate was 56.1% (23/41), the neonatal surgery rate was 53.7% (22/41), and the survival rate was 85.4% (35/41). Intraperitoneal calcification (23 pregnant women, 56.1%), intestinal dilatation (13 pregnant women, 31.7%), peritoneal effusion (22 pregnant women, 53.7%), intraperitoneal pseudocyst (7 pregnant women, 17.1%), and polyhydramnios were diagnosed via prenatal ultrasound (18 pregnant women, 43.9%). Twenty-two pregnant women were assigned to the surgical treatment (operation) group, while 18 were assigned to the conservative treatment group. In the operation group, there were 9 cases of ileal atresia (40.9%), 7 cases of jejunal atresia (31.8%), 2 cases of atresia at the jejunum-ileum junction (9.1%), 2 cases of ileal perforation (9.1%), 1 case of ileal necrosis (4.5%), and 1 case of adhesive obstruction (4.5%). There was no statistically significant difference (p > .05) in the occurrence of various prenatal ultrasound findings by etiology.

CONCLUSION

Multiple prenatal ultrasound markers have been identified for MP. To improve the efficacy of newborn treatment for FMP and reduce neonatal mortality, dynamic monitoring of ultrasound image alterations and strengthened integrated perinatal management are necessary.

Inferior Vena Cava Filter Long Term Complications and Retrieval Techniques: A Case Series and Literature Review

INTRODUCTION AND IMPORTANCE

Long-term mechanical complications after inferior vena cava (IVC) filter placement include embedded or tilted filters, erosion of the vena cava, filter thrombosis. In the setting of caval thrombosis, patients may subsequently develop venous hypertension and post-thrombotic syndrome (PTS). Here we present three unique cases of IVC filter complications and surgical management.

CASE PRESENTATION

A 30-year-old female presented with acute abdominal pain, revealing a duodenal perforation caused by an IVC filter eroding into her duodenum. A 42-year-old female with an IVC filter in place for 20 years due to a prior pulmonary embolism underwent laser-assisted retrieval of the filter due to concerns of caval adherence. A 48-year-old male with a history of DVT, venous stasis ulcer, and an IVC filter presented for filter retrieval.

CLINICAL FINDINGS AND INVESTIGATIONS

The surgical techniques described in this report include complicated IVC filter retrieval, performed in cases of filter complications including migration, fracture, duodenal perforation and IVC thrombosis resulting in PTS. One case, requiring open retrieval, is explained and the surgical technique is provided. There are images and videos of these procedures to enrich the learning experience.

INTERVENTION AND OUTCOMES

The surgical techniques described in this report include complicated inferior vena cava filter retrieval, performed in cases of filter complications including migration, fracture, duodenal perforation and IVC thrombosis. One case, requiring open retrieval, is explained and the surgical technique is provided. There are images and videos of these procedures to enrich the learning experience.

RELEVANCE AND IMPACT

Endovascular retrieval of long-term complicated IVC filters is challenging, but it can be a safely performed in many patients. However, open surgery may be necessary in selected patients.

An unusual cause of abdominal pain in an older female

Toothpick ingestion is an uncommon condition. It has been reported that an estimated incidence of 3.6 toothpick related injuries per 100,000 people per year. However, the incidence of toothpick-related gastrointestinal tract perforation is as high as 80%, with small bowel perforation accounting for 18% of cases. Common symptoms associated with toothpick ingestion include abdominal pain, fever, nausea, diarrhea, and constipation. However, it may lead to peritonitis, abscesses, and sepsis in severe cases. The diagnosis of toothpick ingestion is difficult. Only a minority (12%) of patients remember eating toothpicks and the sensitivity of computed tomography (CT) and endoscopy is 43% and 70%, respectively. When a toothpick penetrates the small intestine or is accompanied by other adverse events such as peritonitis, the vast majority of patients undergo surgery. Double-balloon enteroscopy (DBE) is not only an examination method for small intestinal diseases, but also an endoscopic treatment for the removal of sharp foreign bodies such as toothpicks. We report an elderly woman who was diagnosed as toothpick penetrated the jejunal wall and successfully retrieval under DBE. To our best knowledge, there is currently only one report of removing toothpick from the small intestine using DBE. We figured that DBE is a feasible, safe, and effective treatment when toothpicks penetrate the small intestinal wall without other adverse events based on our presentation.

Spontaneous cecal perforation in a cat diagnosed with ultrasonography

An 8-year-old cat was presented for an acute history of anorexia, marked abdominal pain, and hyperthermia. Ultrasonography showed a cecal perforation with focal steatitis and adjacent free gas bubbles, consistent with focal peritonitis. Surgery confirmed the imaging findings. An enterectomy was performed with the removal of the cecum and ileocolic valve, and anastomosis between the ileum and colon was performed. Histology revealed transmural enteritis and chronic severe pyogranulomatous peritonitis with intralesional plant fragments.

Perforation of barium sulfate enterography in an infant: A case report

RATIONALE

Barium peritonitis is an inflammatory response that occurs when barium accidentally enters the abdominal cavity during a barium test. In extreme circumstances, it has the potential to harm various organs and even result in death.

PATIENT CONCERNS

A 3-month-old infant was diagnosed with multiple organ failure after severe barium peritonitis.

DIAGNOSIS

Multiple organ dysfunction is associated with barium peritonitis.

INTERVENTIONS

The infant underwent surgical intervention and received ventilator support, anti-infection therapy, myocardial nutrition, liver and kidney protection, rehydration, circulation stabilization, and other symptomatic supportive care.

OUTCOMES

The patient experienced clinical death after treatment and resuscitation was unsuccessful.

LESSONS

Barium enema perforation complications are uncommon, but can lead to fatal injuries with a high mortality rate. This case highlights the importance of raising awareness among clinicians about the risks of gastroenterography in infants and children and actively preventing and avoiding similar serious complications. The mortality rate can be reduced by timely multidisciplinary consultation and joint management once a perforation occurs.

Magnets and children: a dangerous combination

BACKGROUND

Accidental ingestion of foreign bodies is a common problem in children. Fortunately, the gastrointestinal tract is quite resilient to foreign bodies. On the other hand, the ingestion of magnets can result in enormous morbidity. Because of their natural tendency to firmly adhere they can cause intestinal obstruction, pressure necrosis, fistula formation or perforation. With this case report, we aim to raise awareness of the risks that these magnets pose to children.

METHODS

We describe a case of intestinal perforation caused by the separate ingestion of multiple magnets from a children's toy (buckyballs, Neodymium spheres) by a two-year-old boy. A search in the Pubmed database showed some publications and varied management guidelines.

RESULTS

The boy was treated with an exploratory laparoscopy converted to a mini-laparotomy. We removed the four magnets through separate enterotomies. Postoperative recovery was uneventful. The boy was discharged on a postoperative day five and had no complications at three months follow-ups.

CONCLUSION

Accidental ingestion of multiple magnets is rare but can create a life-threatening situation in children. If the magnets are still in the stomach, endoscopic retrieval is needed. If they are beyond the stomach, in asymptomatic cases close clinical and radiographic vigilance is mandatory. When symptomatic we advise urgent removal. If treated on time, the surgical outcome is good and fast recovery is expected.

Prediction of surgical outcomes in severe encapsulating peritoneal sclerosis using a computed tomography scoring system

BACKGROUND/PURPOSE

Encapsulating peritoneal sclerosis (EPS) is a rare and potential lethal complication of peritoneal dialysis characterized by bowel obstruction. Surgical enterolysis is the only curative therapy. Currently, there are no tools for predicting postsurgical prognosis. This study aimed to identify a computed tomography (CT) scoring system that could predict mortality after surgery in patients with severe EPS.

METHODS

This retrospective study enrolled patients with severe EPS who underwent surgical enterolysis in a tertiary referral medical center. The association of CT score with surgical outcomes including mortality, blood loss, and bowel perforation was analyzed.

RESULTS

Thirty-four patients who underwent 37 procedures were recruited and divided into a survivor and non-survivor group. The survivor group had higher body mass indices (BMIs, 18.1 vs. 16.7 kg/m2, p = 0.035) and lower CT scores (11 vs. 17, p < 0.001) than the non-survivor group. The receiver operating characteristic curve revealed that a CT score of ≥15 could be considered a cutoff point to predict surgical mortality, with an area under the curve of 0.93, sensitivity of 88.9%, and specificity of 82.1%. Compared with the group with CT scores of <15, the group with CT scores of ≥15 had a lower BMI (19.7 vs. 16.2 kg/m2, p = 0.004), higher mortality (4.2% vs. 61.5%, p < 0.001), greater blood loss (50 vs. 400 mL, p = 0.007), and higher incidence of bowel perforation (12.5% vs. 61.5%, p = 0.006).

CONCLUSION

The CT scoring system could be useful in predicting surgical risk in patients with severe EPS receiving enterolysis.

Delayed Presentation of Bowel Injury Associated with Pelvic Fragility Fracture in Patient with Bladder Sling: A Case Report

CASE

An 85-year-old woman with a history of bladder mesh sling placement sustained a pelvic fracture and extraperitoneal bladder rupture after a ground-level fall. The patient underwent cystorrhaphy and percutaneous anterior column screw placement. Free air was identified on abdominal computed tomography scan on postoperative day 5. Exploratory laparotomy revealed a sigmoid colon perforation and extensive bowel adhesions to the anterior pelvis.

CONCLUSION

This is the first report describing bowel injury and associated bladder rupture in a pelvic fragility fracture related to a prior bladder mesh sling. This case highlights the importance of obtaining a thorough surgical history when treating pelvic injuries.

[A case of small intestinal endometriosis with bowel obstruction and perforation]

A 47-year-old woman was referred to our hospital with recurring lower abdominal pain persisting for more than 2 weeks. Imaging modalities showed small bowel obstruction caused by a mass lesion in the terminal ileum. Despite undergoing fasting, rehydration, and decompression through an ileus tube, her symptoms persisted. Furthermore, the condition deteriorated on day 4, with the onset of her menstrual period. An emergency surgery was conducted on the 7th day after hospitalization. Surgical observations indicated severe stenosis around the ileocecal valve and ileal perforation approximately 40cm from the oral stricture. As a result, ileocecal resection was performed. Pathological examination revealed endometrial tissue infiltration through the mucosal lamina propria to the ileal subserosa. Thus, the patient was identified with intestinal endometriosis of the ileocecum. Endometriosis of the small bowel is an uncommon condition that eventually causes intractable bowel obstruction. Although preoperative diagnosis is considered challenging, intestinal endometriosis should be included in the differential diagnosis in cases of bowel obstruction in women of childbearing age.

Duodenal Diverticular Perforation Treated Conservatively: Reassessing Indications for Treatment

A 59-year-old woman presented with a chief complaint of melena. She had no abdominal findings, such as tenderness or tapping pain. Laboratory tests revealed a white blood cell count of 5,300 cells/μL and C-reactive protein level of 0.07 mg/dL. Inflammation and anemia (hemoglobin 12.4 g/dL) were denied. Contrast-enhanced computed tomography (CT) revealed multiple duodenal diverticula and air surrounding a descending duodenal diverticulum. Based on these findings, duodenal diverticular perforation (DDP) was suspected. Oral food intake was stopped, and nasogastric tube feeding and conservative treatment with cefmetazole, lansoprazole, and ulinastatin were begun. On day 8 of hospitalization, follow-up CT revealed the disappearance of the air surrounding the duodenum, and the patient was discharged on day 19 after the resumption of oral feeding.

Incarcerated hernia with ileal perforation in an extreme preterm infant

We describe a case of a premature 24 weeks gestation infant who presented with clinical lability and abdominal distention with initial concerns of necrotising enterocolitis. On further examination, a right inguinal hernia was noted and serial abdominal X-rays showed bowel loop dilatation with intramural air and no perforation. However, the hernia was recurrent and later found to be not reducible. He underwent right groin exploration. Intraoperatively, distal ileal perforation was noted and he was found to have an additional five sites of perforation. He had a stoma sited at the left iliac fossa as well as primary anastomosis at the site of the second to fifth perforations. He had a stormy postoperative period but is currently doing well. Although obstructed hernias are rare in the initial course of an extreme preterm infant, it should not be missed as a cause of intestinal obstruction and early surgical opinion should be sought.

Laparoscopic management of iatrogenic colon perforation

BACKGROUND

Iatrogenic colon perforation (ICP) due to colonoscopy is a severe complication and is associated with significant morbidity and mortality. The global estimated incidence of ICP is 0.03% and up to 3% for diagnostic and therapeutic colonoscopies, respectively. Treatment options include endoscopic repair, conservative therapy, and surgery. Treatment decision is based on the time and the setting of the diagnosis, the type, and location of the perforation, the presence of related pathologies, the clinical status and characteristic of the patient, and surgeon's skills. We present our experience in the treatment of ICPs.

METHODS

A retrospective review was undertaken of all patients suffering from ICP at Bnai-Zion Medical Center between 1/1/2010 and 1/3/2021. Clinical presentation, therapeutic approach, and short-term outcomes were analyzed.

RESULTS

There were 51 cases of ICPs. Fourteen (27%) were diagnosed by the gastroenterologist during the procedure, 2 of whom were treated with endoscopic clips. The rest of the patients (72.5%) were diagnosed in the ER after a CT scan. Forty-three patients (84%) went on to operative management: 5 (11%) operations started with laparotomy-all were conducted in the early study period (until 2013). All other operations (88%) started with a diagnostic laparoscopy, 4 of whom (10%) were converted to laparotomy. Out of the 38 laparoscopic cases 29 (80%) were treated with primary suturing. Seven patients went on to colon resection (5 of whom with primary anastomosis). Six patients required ICU admission-with 1/38 (2%) from the laparoscopic cases, and 5/9 (55%) from the laparotomy cases. A total of 49/51 (96%) patients recovered and were discharged after 5 ± 2 for conservative and laparoscopic cases, and 12 ± 9 for open cases.

CONCLUSION

Laparoscopic treatment of ICP is safe and feasible in most cases. Our data supports a laparoscopic attempt at any such scenario.

Causes and Management of Endoscopic Retrograde Cholangiopancreatography-Related Perforation: A Retrospective Study

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) is essential for diagnosing and treating biliopancreatic disease. Because ERCP-related perforation can result in death, therapeutic decisions are important. The aim of this study was to determine the cause of ERCP-related perforation and suggest appropriate management.

METHODS

Between January 1999 and August 2022, 7,896 ERCPs were performed in our hospital. We experienced 15 cases (0.18%) of ERCP-related perforation and conducted a retrospective review.

RESULTS

Of the 15 patients, 6 were female and 9 were male, and the mean age was 77.1 years. According to Stapfer's classification, the 15 cases of ERCP-related perforation comprised 3 type I (duodenum), 3 type II (periampullary), 9 type III (distal bile duct or pancreatic duct), and no type IV cases. Fourteen of 15 (92.6%) were diagnosed during ERCP. The main cause of perforation was scope-induced damage, endoscopic sphincterotomy, and instrumentation penetration in type I, II, and III cases, respectively. Four patients with severe abdominal pain and extraluminal fluid collection underwent emergency surgery for repair and drainage. One type III patient with distal bile duct cancer underwent pancreaticoduodenectomy on day 6. Three type III patients with only retroperitoneal gas on computed tomography (CT) performed immediately after ERCP had no symptoms and needed no additional treatment. Seven of the 15 patents were treated by endoscopic nasobiliary drainage (n=5) or CT-guided drainage (n=2). There were no deaths, and all patients were discharged after treatment.

CONCLUSIONS

Early diagnosis and appropriate treatment are important in managing ERCP-related perforation.

Small Intestinal Perforation Caused by Enteric-coated Low-dose Aspirin

A 77-year-old man presented with abdominal pain for 1 week. He was taking enteric-coated low-dose aspirin (LDA) to prevent secondary cardiovascular events and a proton pump inhibitor (PPI). Computed tomography indicated a small intestinal perforation; thus, small intestine resection was performed. Two months after surgery, he experienced a recurrence of the perforation. Since his repeated perforation was suspected to be due to LDA, LDA was discontinued. He has experienced no further recurrence since then. This is the first case of small intestinal perforation caused by enteric-coated LDA. Enteric-coated LDA may cause small intestinal perforation in patients with severe atherosclerosis under PPI administration.

Dilemma of Blunt Abdominal Trauma in Patients with Crohn's Disease, Can Intestinal Perforation be Missed?

Background

Isolated intestinal injury after blunt abdominal trauma is a rare challenging clinical entity. Patients with Crohn's disease (CD) are considered more prone to spontaneous intestinal perforation rather than normal population However, spontaneous intestinal perforation remains rare. In the literature, there are few cases reports discussing intestinal perforation after blunt abdominal trauma in CD patients.

Objective

Herein, we report a young male patient with CD who had missed traumatic intestinal perforation along with literature review of similar cases.

Case Presentation

A young male patient, known to have CD, was brought to the emergency department after a road traffic accident. He had mild tenderness over his right iliac fossa with no signs of peritonitis. His chest X-rays revealed right-sided pneumothorax. His pan-computed tomography revealed thickened terminal ileum and minimal collection between the intestinal loops that were interpreted as interval regression of his Crohn's disease. On the second day, he remained hemodynamically-stable with no signs of peritonitis but his chest X-rays showed air under diaphragm. A repeated CT showed pneumoperitoneum, air foci around the terminal ileum and mild free fluid. An ileal perforation was found around 25 cm from the ileo-cecal valve. The involved ileal segment was completely resected with double-barrel ileostomy.

Conclusion

Traumatic intestinal injury in patients with Crohn's disease represent both diagnostic and management dilemma. Inaccurate interpretation of radiological signs may lead to a delayed or missed diagnosis and surgical intervention. Abdominal CT scan should be routinely repeated, within 24 hours, for such patients, regardless absence of symptoms or signs suggestive of intestinal perforation.

Insidious Onset of Localised Small Intestinal Perforation by Ingested Plastic Fork

Ingestion of a foreign body is generally observed in the psychiatric patients and children. Healthy adult individuals may also swallow a foreign body unintentionally. Here, we report a case of a patient who swallowed a plastic fork and treated with laparoscopic repair. A 46-year man was admitted to the emergency room with the abdominal pain. His physical evaluation and diagnostic imaging revealed free air in the abdomen. Further imaging with CT scan showed a foreign body in the proximal ileum. On taking details of his swallowing history, he remembered swallowing a broken part of a plastic fork unwittingly during dinner. Following the removal of the foreign body, the perforation area was primarily repaired in double layers. The postoperative course was uneventful. An accurate diagnosis of the small intestinal perforation caused by the ingested foreign bodies, particularly in cases where the patient is unaware of the ingestion, can be difficult. CT scan is a useful tool when available to establish the diagnosis before the surgical intervention. Key Words: Small intestine, Perforation, Foreign body, Laparoscopic surgery.