Primary tubercular caecal perforation: a rare clinical entity

Primary cecal pathologies presenting as acute abdomen and critical appraisal of their current management strategies in emergency settings with review of literature

Background:

The importance of cecal pathologies lie in the fact that being the first part of the large intestine, any disease involving the cecum affects the overall functioning of the large bowel. Primary cecal pathologies presenting as acute abdomen have not been described in any previous study in terms of presentation, management, and outcome.

Objectives:

The objective of this study was to identify the reported causes of primary cecal pathologies presenting as acute abdomen and the various causes presenting in our setting, the to discuss morbidity and mortality associated with cecal pathologies, and to critically analyze the various management modalities employed in an emergency setting.

Materials and Methods:

This is a retrospective analysis of a prospectively collected data of all adult patients admitted to our unit in the last 10 years for acute abdomen, in whom cecal pathology was identified as the primary offending agent.

Results:

Our analysis of 43 patients revealed cecal perforation secondary to amebic colitis along with the simultaneous presence of liver abscess to be the most common primary cecal entity met in practice as acute abdomen. Other pathologies that were encountered included volvulus, diverticulitis, and idiopathic typhlitis. Primary acute cecal pathologies are associated with high mortality rates (≈42%). Delay in diagnosis seems to be the most important factor contributing to high mortality as these conditions are commonly misdiagnosed as appendicular pathology. Most of our patients were managed by conservative colonic resection with proximal diversion. This seems to be a more plausible option in current practice in an emergency setting (mortality rate ≈ 36%) as hemicolectomy is associated with proportionately higher mortality rates (67%).

Conclusion:

A high index of suspicion, timely and adequate pre-operative workup, optimal resuscitation, and surgical conservatism with proximal diversion might help in early accurate identification of these conditions and possibly improved outcome.

Caecal perforation from TB and the Law of Laplace

A 43-year-old man presented to the hospital with haemoptysis. When worked up, his history and examination were highly suggestive of pulmonary tuberculosis (TB). He subsequently developed a massive upper gastrointestinal bleed and underwent an emergency laparotomy, which revealed a massively dilated caecum measuring ∼20 cm in diameter. The caecum had perforated due to acute decompensation of intestinal TB. Though common in developing countries, TB is rare in the UK, especially the intestinal kind. The most striking feature of this case is, however, the size of the caecal distension caused by the tubercular inflammation and subsequent perforation—something unheard of in the literature. This massive caecal distention would be explained by the Law of Laplace. In conclusion, massive distension and caecal perforation are possible consequences of intestinal TB, especially in the 48–72 h immediately after starting anti-tubercular therapy.

Isolated caecal tuberculosis mimicking a neoplastic tumour in an immunocompetent woman

Although tuberculosis is endemic in Tunisia, only a few cases of intestinal disease have been reported. This entity is usually associated with pulmonary tuberculosis. Any part of the gastrointestinal tract may be affected but usually with ileocaecal involvement. Diagnosis is extremely difficult because the clinical presentation is so variable. The disease frequently mimics other chronic inflammatory intra-abdominal diseases or even malignancy. We report a case of isolated colonic tuberculosis presenting as circumferential ulcerovegetative lesions in the caecal region.

Primary tuberculous appendicitis presented with caecal perforation: a case report

Gastrointestinal tuberculosis accounts for 3% of the extrapulmonary tuberculosis with ileocaecal region being the common site of involvement up to 75%. Primary involvement of appendix is very rare and accounts for only 0.6% to 2.9% of gastrointestinal tuberculosis in the absence tubercular focus elsewhere. The pre-operative investigations usually give non-specific results. The diagnosis in most instances made only after histopathology. Here we report a case of primary appendicular tuberculosis in a patient presented with caecal perforation.

Appendicular perforation at the base of the caecum, a rare operative challenge in acute appendicitis, a literature review

Background

Acute appendicitis is the most common acute surgical condition of the abdomen. Diagnosis is made based on full clinical history and examination as well as supported by a routine blood investigation and urine test. Prompt diagnosis and surgical referral may reduce the risk of perforation and prevent complications. The mortality rate of non-perforated appendicitis is less than 1 percent. Perforated appendicitis is associated with a higher mortality rate - as high as five percent and may be particularly more in extreme of age group attributed to delay in clinical presentation or diagnosis in the younger group and multiple co-morbidities in the elderly group. The aetiology is unknown. It may be linked with lack of fibre, familial tendency, or viral infection. It may be precipitated by faecaliths. The commonest site of the appendix is retrocaecal.

Case Report

We report a case of a 46 year old male who was admitted under the surgical service in Mid-Western Regional Hospital, Limerick with suspected appendicitis which turned out to be a perforated caecum, a rare complication of an acute appendicitis. We performed a literature review comparing two main approaches - right hemicolectomy and primary closure with omental patch - discuss and highlight their differences as well as a guide to its management.

Conclusion

There are limited studies to compare these two surgical options in the literature. A larger prospective study is needed to compare both approaches and long term outcome.