Perforated ulcers in critical illness

Pneumoperitoneum in dogs and cats: 39 cases (1983-2002)

OBJECTIVE

To identify the most common causes of pneumoperitoneum in dogs and cats and determine history, clinical features, and outcome of affected animals.

DESIGN

Retrospective study.

ANIMALS

31 dogs and 8 cats.

PROCEDURES

Medical records were reviewed for signalment; history; abnormal physical, clinicopathologic, and radiographic findings; results of cytologic analysis and bacterial culture of abdominal fluid; gross and histologic findings at surgery or necropsy; and outcome.

RESULTS

Pneumoperitoneum was classified as spontaneous in 25 animals and traumatic in 14. Causes of traumatic pneumoperitoneum included vehicular impact, gunshot wounds, abdominal dog bite wounds, and iatrogenic pneumothorax. Spontaneous pneumoperitoneum was caused by gastrointestinal tract perforation in 23 animals; underlying causes included neoplasia, nonsteroidal anti-inflammatory drug administration, and corticosteroid administration. Two animals developed spontaneous pneumoperitoneum after bladder rupture. Animals with spontaneous pneumoperitoneum were significantly older and had clinical signs of longer duration than those with traumatic pneumoperitoneum. Sixteen animals survived, including 15 of 23 animals that underwent surgery. Animals that survived had significantly higher serum albumin concentrations than did animals that died or were euthanatized.

CONCLUSIONS AND CLINICAL RELEVANCE

Although pneumoperitoneum is most often attributable to perforation of a hollow viscus, other causes do exist. Early exploration is recommended for diagnosis and treatment of the underlying condition.

Spontaneous gastrointestinal perforation in patients with lymphoma receiving chemotherapy and steroids. Report of three cases

Spontaneous gastrointestinal perforations in three patients with lymphoma were considered to be treatment-related conditions. All three were diagnosed as having malignant lymphoma by histological examination, and treated with chemotherapy and steroids. Four to 14 days after the start of chemotherapy, they complained of abdominal pain and plain roentgenograms revealed pneumoperitoneum. The interval between the onset of peritonitis and operation was almost 24 h. Emergency operations were carried out; one patient with a jejunal perforation underwent resection of the jejunum, another with a gastric perforation received a simple closure with omental patch, and the third with a gastric perforation underwent gastrectomy. Two patients recovered from the surgery, while the gastrectomy patient died due to sepsis. The favorable outcome of the surgical intervention is attributed to early diagnosis, prompt exploration, and selective operative procedures. We recommended a simple closure with omental patch for gastroduodenal perforation. Resection and primary anastomosis are possible only in the small bowel.

Traumatic and nontraumatic perforation of hollow viscera

Hollow viscus injuries are usually managed with few complications. However, if their diagnosis is delayed, or if reparative suture closure should fail, the patient is placed at risk of multiple organ failure. This article presents diagnostic approaches, emphasizing imaging modalities, and therapeutic strategies for three clinical scenarios of hollow viscus perforation: 1) acute appendicitis, 2) gastroduodenal peptic ulcer disease, and 3) trauma.

The acute abdomen in the critically ill patient

The critically ill patient with an acute abdomen represents a great challenge for the surgeon. The physiologic derangement that is associated with the critically ill state both fuels and is fueled by acute abdominal processes. Improvements in critical care and cardiopulmonary bypass technique have allowed for a group of patients to evolve that are susceptible to the complications of prolonged flow states. This article focuses on the abdominal consequences of support of the critically ill patient, as well as, the diagnostic and therapeutic options that are available to treat these patients.

Frequency of stress lesions of the upper gastrointestinal tract in paediatric patients after cardiac surgery: effects of prophylaxis

BACKGROUND

Stress lesions of the upper gastrointestinal tract are well recognised in adult patients in intensive care. There are no controlled studies of the incidence of these lesions and the effects or side effects of prophylactic treatment in high risk paediatric patients.

METHODS

79 paediatric patients in intensive care were studied prospectively after operation for congenital heart disease. All patients had at least one endoscopic examination. The first 36 patients were not given prophylactic medication: later 43 children were treated randomly either with pirenzepine (n = 21) or with famotidine (n = 22). Gastric and tracheal secretions were taken daily for culture in those patients given prophylactic medication.

RESULTS

Severe inflammation or ulceration of the upper gastrointestinal tract was less common in those patients who were given prophylactic medication (18% v 44%). Prophylactic treatment did not, however, reduce the total incidence of postoperative stress lesions: it shifted the severity of these changes towards mild lesions and reduced the incidence of ulcerations from 25% to 2%. None of the patients developed a pneumonia caused by an organism previously isolated from the stomach.

CONCLUSIONS

The incidence of stress lesions in children after cardiac surgery resembles that in high risk adult patients. Children in intensive care after cardiac surgery should be treated prophylactically with famotidine or pirenzepine until they can be fed by mouth.

Spontaneous gastroduodenal perforation in patients with cancer receiving chemotherapy and steroids. Report of four cases combining 5-fluorouracil infusion and cisplatin with antiemetics dexamethasone

BACKGROUND

Spontaneous gastroduodenal perforation is an uncommon but life-threatening complication of systemic chemotherapy and/or steroids. Here, the authors reported four cases of gastroduodenal perforation following combined chemotherapy with steroids.

METHODS

The chemotherapeutic regimens all included 5-fluorouracil (5-FU) by continuous infusion and cisplatin. The authors used dexamethasone as an antiemetic. All patients took analgesics for pain relief. No patient had a history of peptic ulcer disease.

RESULTS

Severe epigastralgia occurred 3-5 days after the start of chemotherapy. The peptic ulcer perforations were diagnosed within 3 days of onset of symptoms. All patients had an emergency laparotomy. Three of the perforations were located in the duodenum and one was located in the stomach. Pathologic examination of one patient revealed a chronic peptic ulcer. Two patients with preoperative shock died in the postoperative period.

CONCLUSIONS

The cause of spontaneous gastroduodenal perforation is not known, but the etiology can be complex. Either 5-FU or steroids can induce the perforation. An asymptomatic peptic ulcer may be aggravated by 5-FU, cisplatin, or dexamethasone. The authors suggest that patients receiving 5-FU infusion and cisplatin with dexamethasone for antiemesis who complain of epigastric pain should be mentioned for a gastroduodenal ulcer or even a perforation.

Spontaneous gastroduodenal perforation in cancer patients receiving cytotoxic therapy

Spontaneous gastroduodenal perforation (SGDP) occurs in cancer patients receiving cytotoxic drugs, corticosteroids, or radiation therapy as primary or adjuvant treatment for their tumors. A retrospective review identified 12 patients from 1974 to 1987 at the Memorial Sloan-Kettering Cancer Center who underwent surgery for SGDP while receiving anticancer therapy. There were five gastric and seven duodenal perforations. Vague abdominal pain was the most common symptom. Exploration was delayed in six patients because of an absence of physical findings. All patients received a Graham omental patch. The in-hospital operative mortality was 33%, with all major complications occurring in those that died. There were no prognostic indicators identified that would preoperatively predict outcome. Aggressive surgical intervention is advised in all patients who have a reasonable chance of worthwhile palliation if not cure.