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Dourado J, Jassir FF, Pavlovsky A, Blumofe K. Perforated jejunal diverticulitis in the setting of biologic therapy presenting as transverse Colon diverticulitis: A case report. Int J Surg Case Rep 2024; 118:109615. [PMID: 38615466 PMCID: PMC11033175 DOI: 10.1016/j.ijscr.2024.109615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 03/30/2024] [Accepted: 04/03/2024] [Indexed: 04/16/2024] Open
Abstract
INTRODUCTION Small bowel diverticula are a rare entity and are mostly found in the duodenum on diagnosis. Some common complications of this pathology include bleeding, obstruction, diverticulitis, and perforation. Furthermore, there is growing evidence supporting an association between biologic therapies and spontaneous intestinal perforation. PRESENTATION OF CASE We present a case of a 79-year-old female on prednisone, hydroxychloroquine, and tofacitinib for rheumatoid arthritis who was misdiagnosed with transverse colonic diverticulitis and eventually found to have perforated jejunal diverticulitis on laparotomy. DISCUSSION While tofacitinib has been associated with spontaneous intestinal perforation, it has not been documented as an aggravating factor in small bowel diverticular disease. CONCLUSION It is imperative to maintain a high index of suspicion for this pathology in immunosuppressed patients with an atypical presentation of diverticular disease.
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Affiliation(s)
- Justin Dourado
- Florida Atlantic University, Department of General Surgery, Boca Raton Regional Hospital, Boca Raton, FL, United States of America.
| | - Fauzi Feris Jassir
- Florida Atlantic University, Department of General Surgery, Boca Raton Regional Hospital, Boca Raton, FL, United States of America
| | - Arthur Pavlovsky
- Florida Atlantic University, Department of General Surgery, Boca Raton Regional Hospital, Boca Raton, FL, United States of America
| | - Karin Blumofe
- Florida Atlantic University, Department of General Surgery, Boca Raton Regional Hospital, Boca Raton, FL, United States of America
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Herbawi AN, Hroub O, Salloum OH, Ibraheem K, Alsalah QA, Hammouri AG, Salhab R. Perforated small bowel lymphoma: a rare presentation of Crohn's disease. J Surg Case Rep 2024; 2024:rjae135. [PMID: 38469205 PMCID: PMC10927353 DOI: 10.1093/jscr/rjae135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2024] [Accepted: 02/15/2024] [Indexed: 03/13/2024] Open
Abstract
Adenocarcinoma and lymphoma, potential complications of Crohn's disease (CD), may result in small intestinal perforations, particularly in those on immunosuppressive therapy. The ileum is typically the site of small intestinal perforations in CD, and the link between CD and lymphoma remains uncertain. This case report explores a long-term CD patient on immunosuppressive therapy who presented with acute abdominal pain. Imaging revealed signs of intestinal perforation, successfully managed with surgery. The final pathology report confirms the diagnosis of diffuse large B-cell lymphoma. This report sheds light on the complicated nature of gastrointestinal lymphoma in CD patients.
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Affiliation(s)
| | - Osama Hroub
- Faculty of Medicine, Palestine Polytechnic University, Hebron 9020000, Palestine
| | - Omar H Salloum
- Faculty of Medicine, Palestine Polytechnic University, Hebron 9020000, Palestine
| | - Kareem Ibraheem
- Faculty of Medicine, Palestine Polytechnic University, Hebron 9020000, Palestine
| | - Qusai A Alsalah
- Faculty of Medicine, Palestine Polytechnic University, Hebron 9020000, Palestine
| | - Ahmad G Hammouri
- Radiology Department, Al-Ahli Hospital, Hebron 9020000, Palestine
| | - Rafiq Salhab
- Faculty of Medicine, Palestine Polytechnic University, Hebron 9020000, Palestine
- General Surgery Department, Al-Ahli Hospital, Hebron 9020000, Palestine
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3
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Onken F, Senne M, Königsrainer A, Wichmann D. Classification und Treatment Algorithm of Small Bowel Perforations Based on a Ten-Year Retrospective Analysis. J Clin Med 2022; 11:jcm11195748. [PMID: 36233616 PMCID: PMC9572575 DOI: 10.3390/jcm11195748] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 09/19/2022] [Accepted: 09/24/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Small bowel perforations are a rare diagnosis compared with esophageal, gastric, and colonic perforations. However, small bowel perforations can be fatal if left untreated. A classification of small bowel perforations or treatment recommendations do not exist to date. Methods: A retrospective, monocentric, code-related data analysis of patients with small bowel perforations was performed for the period of 2010 to 2019. Results: Over a 10-year period, 267 cases of small bowel perforation in 257 patients (50.2% male and 49.8% female; mean age of 60.28 years) were documented. Perforation’s localization was 5% duodenal, 38% jejunal, 39% ileal, and 18% undocumented. Eight etiologies were differentiated: iatrogenic (41.9%), ischemic (20.6%), malignant (18.9%), inflammatory (8.2%), diverticula-associated (4.5%), traumatic (4.5%), foreign-body-associated (1.9%), and cryptical (1.5%) perforations. Operative treatment combined with antibiotics was the most commonly used therapeutic approach (94.3%). The mortality rate was 14.23%, with highest rate for patients with ischemic perforations. Discussion: An algorithm for diagnostic and therapeutic steps was established. Furthermore, it was found that small bowel perforations are rare events with poor outcomes. Time to diagnosis and grade of underlying disease are the most essential parameters to predict perforation-associated complications.
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Affiliation(s)
- Flurina Onken
- Department of General, Visceral and Transplantation Surgery, University Hospital of Tübingen, Hoppe-Seyler-Str. 3, 72076 Tübingen, Germany
- Department of Anesthesia and Intensive Care Medicine, University Hospital of Tübingen, Hoppe-Seyler-Str.3, 72076 Tübingen, Germany
| | - Moritz Senne
- Department of General, Visceral and Transplantation Surgery, University Hospital of Tübingen, Hoppe-Seyler-Str. 3, 72076 Tübingen, Germany
- Correspondence: ; Tel.: +49-7071-2968165
| | - Alfred Königsrainer
- Department of General, Visceral and Transplantation Surgery, University Hospital of Tübingen, Hoppe-Seyler-Str. 3, 72076 Tübingen, Germany
| | - Dörte Wichmann
- Department of General, Visceral and Transplantation Surgery, University Hospital of Tübingen, Hoppe-Seyler-Str. 3, 72076 Tübingen, Germany
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Staudenmann D, Choi KKH, Kaffes AJ, Saxena P. Current endoscopic closure techniques for the management of gastrointestinal perforations. Ther Adv Gastrointest Endosc 2022; 15:26317745221076705. [PMID: 35252863 PMCID: PMC8891873 DOI: 10.1177/26317745221076705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 01/11/2022] [Indexed: 11/16/2022] Open
Abstract
Acute gastrointestinal perforations occur either from spontaneous or iatrogenic
causes. However, particular attention should be made in acute iatrogenic
perforations as timely diagnosis and endoscopic closure prevent morbidity and
mortality. With the increasing use of diagnostic endoscopy and advances in
therapeutic endoscopy worldwide, the endoscopist must be able to recognize and
manage perforations. Depending on the size and location of the defect, a variety
of endoscopic clips, stents, and suturing devices are available. This review
aims to prepare and guide the endoscopist to use the right tools and techniques
for optimal patient outcomes.
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Affiliation(s)
- Dominic Staudenmann
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Praxis Intesto, Bern, Switzerland; Université de Fribourg, Fribourg, Switzerland
| | - Kevin Kyung Ho Choi
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, NSW, Australia
- The University of Sydney, Sydney, NSW, Australia
| | - Arthur John Kaffes
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, NSW, Australia
- The University of Sydney, Sydney, NSW, Australia
| | - Payal Saxena
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, 50 Missenden Road, Sydney, NSW 2050, Australia
- The University of Sydney, Sydney, NSW, Australia
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5
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Thompson JS, Mannon P. Celiac disease and the surgeon. Am J Surg 2022; 224:332-338. [PMID: 35221098 DOI: 10.1016/j.amjsurg.2022.02.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 02/14/2022] [Accepted: 02/16/2022] [Indexed: 11/16/2022]
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Wang Y, Lin X, Li Y, Wen Y. Multiple small bowel perforations due to cytomegalovirus related immune reconstitution inflammatory syndrome in an HIV patient: A case report. Medicine (Baltimore) 2021; 100:e26605. [PMID: 34260544 PMCID: PMC8284711 DOI: 10.1097/md.0000000000026605] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 06/22/2021] [Indexed: 01/04/2023] Open
Abstract
RATIONALE The presentation of multiple intestinal perforations is a severe complication of enteric cytomegalovirus (CMV) infection, sometimes associated with immune reconstitution inflammatory syndrome (IRIS) after the initiation of antiretroviral therapy (ART) in patients with human immunodeficiency virus (HIV). Here we reported a rare case of a patient with HIV infection who developed multiple perforations in the small bowel shortly after ART initiation without any prodromal gastrointestinal symptoms. We also reviewed the literature of reported cases to clarify their clinical characteristics for early diagnosis and rapid intervention. PATIENT CONCERNS A patient with HIV presented with fever after 16 days of ART initiation and was admitted to our hospital. He was treated with intravenous ganciclovir due to persistent CMV viremia. The fever resolved 10 days later. However, he reported persistent left lower abdominal pain. DIAGNOSES The patient was diagnosed with multiple small bowel perforations, CMV-related IRIS, and acquired immune deficiency syndrome. An upright abdominal x-ray in a tertiary level hospital revealed bilateral moderate intraperitoneal free air. We performed a pathological examination and metagenomic next-generation sequencing. CMV enteritis was confirmed by immunohistochemical staining and other opportunistic infections were excluded by metagenomic next-generation sequencing. INTERVENTIONS The patient was treated with intravenous ganciclovir and 24 hours later, the patient underwent exploratory laparotomy. Partial resection and surgical repair of the small intestine were performed. OUTCOMES The patient ultimately died from intestinal obstruction and septic shock 55 days after surgery. LESSONS Perforations due to CMV-related IRIS are very rare, and usually appear shortly after ART initiation. Most cases lack the prodromal symptoms of abdominal pain and diarrhea. Intestinal perforations are lethal, and early detection and surgical treatment are lifesaving.
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Affiliation(s)
- Yanli Wang
- Infectious Diseases Department, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Xuyong Lin
- Pathology Department, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Yuji Li
- Gastrointestinal Surgery, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Ying Wen
- Infectious Diseases Department, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning Province, China
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7
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Udelsman B, Lee K, Qadan M, Lillemoe KD, Chang D, Lindvall C, Cooper Z. Management of Pneumoperitoneum: Role and Limits of Nonoperative Treatment. Ann Surg 2021; 274:146-154. [PMID: 31348040 DOI: 10.1097/sla.0000000000003492] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The aim of this study was to compare morbidity and mortality between nonoperative and operative treatment of pneumoperitoneum. BACKGROUND Pneumoperitoneum is a potentially life-threatening condition that has been traditionally treated with surgical intervention. Adequately powered studies comparing treatment outcomes are lacking. METHODS Chart review and computer-assisted abstraction were used to identify patients with pneumoperitoneum at 5 hospitals from 2010 to 2015. Patients with recent abdominal procedures or contained perforation were excluded. Patients were grouped by treatment modality: comfort measures only (CMO), nonoperative treatment, or operative intervention. CMO included only symptom-palliation, whereas nonoperative therapy included all interventions (antibiotics, peritoneal drains, resuscitation) excluding surgery. Outcomes were mortality, discharge disposition, and 30-day complications. Covariates included demographics, comorbidities, and acuity at presentation. RESULTS Forty patients received CMO, 202 underwent nonoperative treatment, and 199 underwent operative intervention. CMO patients had 98% 30-day mortality. There was no difference in 30-day (P = 0.64) or 2-year mortality (P = 0.53) between patients treated nonoperatively and operatively. Compared with patients treated operatively, patients treated nonoperatively were more likely to have a colorectal source of pneumoperitoneum (37% vs 31%; P = 0.03). Using logistic regression, operative treatment was associated with increased dependence on enteral tube feeding or total parenteral nutrition [odds ratio (OR) 4.30, 95% confidence interval (CI), 1.99-9.29] and nonhome discharge (OR 3.61, 95% CI, 1.81-7.17). Among patients with clinical peritonitis, operative treatment was associated with reduced mortality (OR 0.17, 95% CI, 0.04-0.80). CONCLUSIONS Operative intervention is associated with reduced mortality in patients with pneumoperitoneum and peritonitis. In the absence of peritonitis, operative treatment is associated with increased morbidity and nonhome discharge.
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Affiliation(s)
- Brooks Udelsman
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Katherine Lee
- Department of Surgery, University of California San Diego, San Diego, CA
- Center for Surgery and Public Health, Brigham & Women's Hospital, Boston, MA
| | - Motaz Qadan
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Keith D Lillemoe
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - David Chang
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Charlotta Lindvall
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA
- Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - Zara Cooper
- Center for Surgery and Public Health, Brigham & Women's Hospital, Boston, MA
- Department of Surgery, Brigham and Women's Hospital, Boston, MA
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Hirakawa Y, Shigyo H, Katagiri Y, Hashimoto K, Katsumoto M, Tomoeda H, Nakano M. Nontraumatic perforation of the small intestine caused by true primary enteroliths associated with radiation enteritis: a case report. Surg Case Rep 2021; 7:102. [PMID: 33891220 PMCID: PMC8065084 DOI: 10.1186/s40792-021-01182-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 04/13/2021] [Indexed: 11/24/2022] Open
Abstract
Background True primary enterolithiasis is an uncommon condition, and nontraumatic perforation of the small intestine (NTPSI) is also an unusual entity. Therefore, NTPSI due to true primary enteroliths is an exceptionally rare complication. Moreover, enterolithiasis and radiation enteritis are also unique combinations. Herein, we present an exceedingly rare case of NTPSI induced by multiple true primary enteroliths associated with radiation enteritis. Case presentation A 92-year-old woman with acute abdominal pain was transferred to our hospital because a computed tomography (CT) scan performed by her family doctor revealed free air and fluid collection within her abdomen. Our initial diagnosis was upper gastrointestinal perforation, and we selected nonoperative management (NOM) with adnominal drainage. Although her general condition was stable, jejunal juice was drained continuously. Given that the CT performed 10 days after onset demonstrated perforation of the small intestine and adjacent concretion, we performed an emergency partial resection of the small intestine and jejunostomy. The resected bowel was 1 m in length and had many strictures that contained multiple enteroliths in their proximal lumens. The patient’s postoperative course was uneventful. The enteroliths were composed of deoxycholic acid (DCA). She was diagnosed with peritonitis due to NTPSI derived from multiple true primary enteroliths associated with radiation enteritis, as she had previously undergone hysterectomy and subsequent internal radiation therapy. Conclusions Clinicians should consider the rare entity of true primary enteroliths associated with radiation enteritis in NTPSI cases with unknown etiologies.
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Affiliation(s)
- Yusuke Hirakawa
- Department of Surgery, Chikugo City Hospital, 917-1 Izumi, Chikugo, Fukuoka, 833-0011, Japan.
| | - Hirona Shigyo
- Department of Surgery, Chikugo City Hospital, 917-1 Izumi, Chikugo, Fukuoka, 833-0011, Japan
| | - Yuriko Katagiri
- Department of Surgery, Chikugo City Hospital, 917-1 Izumi, Chikugo, Fukuoka, 833-0011, Japan
| | - Kazuaki Hashimoto
- Department of Surgery, Chikugo City Hospital, 917-1 Izumi, Chikugo, Fukuoka, 833-0011, Japan
| | - Mitsuru Katsumoto
- Department of Surgery, Chikugo City Hospital, 917-1 Izumi, Chikugo, Fukuoka, 833-0011, Japan
| | - Hiroshi Tomoeda
- Department of Surgery, Chikugo City Hospital, 917-1 Izumi, Chikugo, Fukuoka, 833-0011, Japan
| | - Masahiko Nakano
- Department of Surgery, Chikugo City Hospital, 917-1 Izumi, Chikugo, Fukuoka, 833-0011, Japan
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Chien SC, Chang CC, Chien SC. Spontaneous small bowel perforation secondary to Vibrio parahaemolyticus infection: A case report. World J Clin Cases 2021; 9:1210-1214. [PMID: 33644186 PMCID: PMC7896667 DOI: 10.12998/wjcc.v9.i5.1210] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 12/21/2020] [Accepted: 01/07/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Vibrio pararhaemolyticus (V. parahaemolyticus), a pathogen that commonly causes gastroenteritis, could potentially lead to a pandemic in Asia. Its pathogenesis and molecular mechanisms vary, and the severity of illness can be diverse, ranging from mild gastroenteritis, requiring only supportive care, to sepsis.
CASE SUMMARY We outline a case of a 71-year-old female who experienced an acute onset of severe abdominal tenderness after two days of vomiting and diarrhea prior to her emergency department visit. A small bowel perforation was diagnosed using computed tomography. The ascites cultured revealed infection due to V. parahaemolyticus
CONCLUSION Our case is the first reported case of V. parahaemolyticus-induced gastroenteritis resulting in small bowel perforation.
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Affiliation(s)
- Shih-Chun Chien
- Department of Emergency Medicine, Mackay Memorial Hospital, Taipei 104, Taiwan
| | - Chih-Chung Chang
- Department of Emergency Medicine, Taitung Mackay Memorial Hospital, Taitung 950, Taiwan
| | - Shih-Chao Chien
- Department of Emergency Medicine, Mackay Memorial Hospital, Taipei 104, Taiwan
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Presentation with perforation of the terminal ileum and acute limb ischemia in Crohn's disease: A case report. Int J Surg Case Rep 2021; 80:105626. [PMID: 33601328 PMCID: PMC7898057 DOI: 10.1016/j.ijscr.2021.02.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 02/03/2021] [Accepted: 02/04/2021] [Indexed: 12/30/2022] Open
Abstract
Crohn’s disease may be revealed by serious complications. Initial free peritoneum perforation in Crohn’s disease is uncommon and remains life threatening. Thromboembolic events revealing Crohn’s disease is exceptional. Our case is unique because of the association of two initial rare conditions revealing Crohn’s disease.
Introduction and importance Crohn’s disease is a chronic inflammatory bowel disease with complex pathophysiology and multiple complications, some of which can be fatal. We report herein the management of an unusual case of Crohn’s disease revealed by two life-threatening complications. Case presentation A 59-year-old patient presented with an acute abdominal pain evolving for one day with a clinical presentation in favor of peritonitis by perforation of the last ileal loop and acute limb ischemia. At emergency laparotomy, we found a fecal peritonitis by perforation of the last ileal loop. The patient underwent an ileo-caecal resection with rifle barrel ileo-colostomy associated with embolectomy using a Fogarty catheter of the femoral artery. Pathological examination of the specimen showed an aspect consistent with an ileo-caecal Crohn's disease and blood clot embolus of the femoral artery. Postoperative course was uneventful and the patient was kept in remission with immunosuppressants. Discussion Several complications may arise during the evolution of the disease. However, Life-threatening complication scarcely inaugurate crohn’s disease like in our patient. Free perforation of the small intestine in crohn’s disease occurs rarely, which makes its statistical study difficult. Risk factors for perforation are still poorly identified. Patients diagnosed with crohn's disease have a higher risk of thromboembolic complications. Indeed, there is an association between the activity of the disease and thromboembolic events. In our case, the severity of the clinical presentation as well as its inaugural character are unique. Conclusion The management of inaugural two uncommon acute conditions in Crohn’s disease is challenging.
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Rai A, Gajula B, Kumar N, Malik A. Gastric Perforation Secondary to Fungal Gastritis in an Immuno-Competent Adult. Cureus 2021; 13:e13156. [PMID: 33692925 PMCID: PMC7937405 DOI: 10.7759/cureus.13156] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Gastrointestinal (GI) tract perforation is a surgical emergency. The epidemiology and etiology of perforation vary considerably across geography. Lower GI tract perforations in the elderly predominate in the West compared to upper GI perforations in the younger population in the tropics. Fungi and viruses have been reported to cause GI perforations in immuno-compromised individuals but it is rare in immuno-competent individuals. We report a very rare case of gastric perforation secondary to fungal gastritis in an immuno-competent 35-year-old female who presented with features of peritonitis. At emergency laparotomy, gastric perforation was found which was repaired by the Cellan-Jones method. Perforation edge biopsy findings were consistent with fungal etiology. She responded well to Antifungal therapy. We conclude that fungal etiology can be considered in patients with gastric perforation without any history of peptic ulcer disease (PUD) or use of oral non-steroidal anti-inflammatory drugs.
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Affiliation(s)
- Ankit Rai
- General Surgery, All India Institute of Medical Sciences Rishikesh, Rishikesh, IND
| | - Bhargav Gajula
- General Surgery, All India Institute of Medical Sciences Rishikesh, Rishikesh, IND
| | - Navin Kumar
- General Surgery, All India Institute of Medical Sciences Rishikesh, Rishikesh, IND
| | - Akanksha Malik
- Pathology, National Institute of Pathology, New Delhi, IND.,Pathology, All India Institute of Medical Sciences Rishikesh, Rishikesh, IND
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A systemic review and metaanalysis of postoperative outcomes in urgent and elective bowel resection in patients with Crohn's disease. Int J Colorectal Dis 2021; 36:253-263. [PMID: 33048241 DOI: 10.1007/s00384-020-03786-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/09/2020] [Indexed: 02/06/2023]
Abstract
PURPOSE The study examined whether urgency of surgical intervention affects postoperative outcomes in patients with Crohn's disease (CD) undergoing bowel resection. METHOD The review was conducted according to a predefined, published study protocol in Prospero which is an international database of prospectively registered systematic reviews in health. The study reported according to PRIMSMA guidelines. We searched Embase and Pubmed for articles reporting postoperative outcome after urgent and elective surgery in patients with CD undergoing bowel resection. Primary outcome variable was 30-day overall postoperative complications while secondary outcome variables were intraabdominal septic complications (IASCs), mortality, reoperation, and readmission. Assessment of bias was performed using Newcastle-Ottawa score. Two authors independently extracted data on each study, patients, and outcome measures. RESULTS The search identified 22 studies in which 955 patients underwent urgent surgeries while 6518 patients underwent elective surgeries. Based on the quality assessment, 19 studies were classified as having high risk of bias, one study as having a medium risk of bias and 2 studies as having low risk of bias (≥ 8 stars). Random-effect metaanalysis showed urgent surgery was associated with ~ 40% increase in overall complications compared to elective surgery (RR = 1.43, 95% CI [1.09; 1.87], p = 0.010). IASCs also increased in patients who had urgent surgery (RR = 1.44, 95% CI [1.08; 1.92], p = 0.013). No significant difference was shown in mortality and readmission rates. CONCLUSION Urgent bowel resection in patients with CD is associated with higher risk of overall postoperative complications and IASCs.
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13
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Nomura M, Sumiya R, Ono H, Nagai T, Kumazawa K, Shimizu A, Endo D, Aoyanagi N. Cessation of methotrexate and a small intestinal resection provide a good clinical course for a patient with a jejunum perforation induced by a methotrexate-associated lymphoproliferative disorder: a case report. World J Surg Oncol 2021; 19:4. [PMID: 33388058 PMCID: PMC7778788 DOI: 10.1186/s12957-020-02114-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 12/16/2020] [Indexed: 01/17/2023] Open
Abstract
Background Methotrexate (MTX) is a frequently used drug in the treatment of rheumatoid arthritis (RA), but occurrences of lymphoproliferative disorders (LPD) have been reported in patients undergoing an MTX regimen. Almost half of the patients with methotrexate-associated lymphoproliferative disorders (MTX-LPD) have extranodal lesions; moreover, although extremely rare, digestive tract perforations resulting from the extranodal lesions of MTX-LPD have also been reported. Case presentation We describe the case of an 81-year-old woman with RA who had been prescribed MTX at 6 mg per week for the past 11 years. She was admitted to our hospital with occasional abdominal pain and was first diagnosed with enteritis. Her abdominal pain did not improve, and a computed tomography scan showed abdominal effusion and free air in the abdominal cavity. She was diagnosed with a digestive tract perforation and underwent emergency surgery. The perforation site was identified in the jejunum, and she underwent small intestinal resection around the perforated region. The pathological findings showed an ulcer in the jejunum and infiltration of large atypical lymphocytes around the perforated region. An immunohistochemical examination revealed the expression of a cluster of differentiation 20 and latent membrane protein 1. Considering the patient’s history of RA treated with MTX, she was diagnosed as having Epstein–Barr virus (EBV)-related MTX-LPD with a histological diagnosis of EBVMCU. MTX was discontinued after the surgery, and her soluble interleukin-2 receptor (sIL-2R) levels had returned to normal 1 year later. She has had a good course for the 2 years since surgery and remains asymptomatic with no recurrence of MTX-LPD, as confirmed by the sIL-2R levels. Conclusion We experienced a rare case of the jejunum perforation induced by MTX-LPD. Since only a few cases have been reported of a patient with small intestinal perforation induced by MTX-LPD, further research is necessary to evaluate the clinicopathological features of MTX-LPD. The patient had disease remission after surgery and by discontinuing MTX treatment; our case did not require chemotherapy. EBV-positive patients, especially those with a pathological presentation of EBVMCU, could have a higher likelihood of remission, which could have been a factor in the present case.
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Affiliation(s)
- Masahiro Nomura
- Department of Surgery, Kohnodai Hospital, National Center for Global Health and Medicine, 1-7-1 Konodai, Ichikawa-shi, Chiba, 272-8156, Japan
| | - Ryusuke Sumiya
- Department of Surgery, Kohnodai Hospital, National Center for Global Health and Medicine, 1-7-1 Konodai, Ichikawa-shi, Chiba, 272-8156, Japan.
| | - Hayato Ono
- Department of Surgery, Kohnodai Hospital, National Center for Global Health and Medicine, 1-7-1 Konodai, Ichikawa-shi, Chiba, 272-8156, Japan
| | - Takeshi Nagai
- Department of Surgery, Kohnodai Hospital, National Center for Global Health and Medicine, 1-7-1 Konodai, Ichikawa-shi, Chiba, 272-8156, Japan
| | - Keigo Kumazawa
- Department of Surgery, Kohnodai Hospital, National Center for Global Health and Medicine, 1-7-1 Konodai, Ichikawa-shi, Chiba, 272-8156, Japan
| | - Atsushi Shimizu
- Department of Surgery, Kohnodai Hospital, National Center for Global Health and Medicine, 1-7-1 Konodai, Ichikawa-shi, Chiba, 272-8156, Japan
| | - Daisuke Endo
- Department of Surgery, Kohnodai Hospital, National Center for Global Health and Medicine, 1-7-1 Konodai, Ichikawa-shi, Chiba, 272-8156, Japan
| | - Nobuyoshi Aoyanagi
- Department of Surgery, Kohnodai Hospital, National Center for Global Health and Medicine, 1-7-1 Konodai, Ichikawa-shi, Chiba, 272-8156, Japan
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DEMİRLİ ATICI S, YEŞİLYURT D, AKPINAR G, ÜSTÜN M, AYDIN C. Spontaneous Perforation of Jejunal Ulcer. DÜZCE TIP FAKÜLTESI DERGISI 2020. [DOI: 10.18678/dtfd.609647] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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15
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Lee YC, Chiou CC, Wang JT, Yang YC, Tung SH, Hsieh SM. Non-traumatic perforation of the jejunum in a human immunodeficiency virus-infected patient receiving combination antiretroviral therapy: A case report. Medicine (Baltimore) 2019; 98:e18163. [PMID: 31804330 PMCID: PMC6919416 DOI: 10.1097/md.0000000000018163] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
RATIONALE Non-traumatic bowel perforation caused by cytomegalovirus (CMV) and Mycobacterium avium complex (MAC) infections has become rare among patients with acquired immunodeficiency syndrome (AIDS) in the era of combination antiretroviral therapy (cART); however, CMV-associated and MAC-related immune reconstitution inflammatory syndrome (IRIS) has subsequently emerged owing to the wide use of integrase inhibitor-based regimens. Here we report a case of spontaneous perforation of the jejunum in a patient with human immunodeficiency virus (HIV) infection with good compliance to cART. PATIENT CONCERNS A 32-year-old HIV-infected man developed CMV disease and DMAC infection, as unmasking IRIS, 3 days after the initiation of cART. After appropriate treatment for opportunistic infections, intermittent fever with enlarged lymph nodes in the abdomen occurred as paradoxical IRIS. The patient was administered prednisolone with subsequent tapering according to his clinical condition. DIAGNOSES Unexpected perforation of hollow organ during the titration of steroid dose with clinical presentations of severe abdominal pain was diagnosed by chest radiography. INTERVENTIONS He underwent surgical repair with peritoneal toileting smoothly. OUTCOMES He was discharged well with a clean surgical wound on post-operative day 10. LESSONS Bowel perforation may be a life-threatening manifestation of IRIS in the era of cART. Steroids should be avoided, if possible, to decrease the risk of bowel perforation, especially in IRIS occurred after opportunistic diseases involving the gastrointestinal tract.
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Affiliation(s)
- Yi-Chien Lee
- Department of Internal Medicine, Fu Jen Catholic University Hospital
- School of Medicine, College of Medicine, Fu Jen Catholic University, New Taipei City
| | - Chien-Chun Chiou
- Department of Dermatology, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chia-Yi
| | - Jann-Tay Wang
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei
- Institute for Infectious Diseases and Vaccinology, National Health Research Institutes
| | - Yi-Chun Yang
- Department of Nursing, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chia-Yi, Taiwan
| | - Shao-Hsien Tung
- Department of Internal Medicine, Fu Jen Catholic University Hospital
| | - Szu-Min Hsieh
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei
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16
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Affiliation(s)
- Andrew R Lai
- From the Department of Medicine, University of California, San Francisco (A.R.L., L.S., L.S.G., K.M., G.D.), and the Medical Service, San Francisco Veterans Affairs Medical Center (L.S.G., K.M., G.D.) - both in San Francisco
| | - Leslie Sheu
- From the Department of Medicine, University of California, San Francisco (A.R.L., L.S., L.S.G., K.M., G.D.), and the Medical Service, San Francisco Veterans Affairs Medical Center (L.S.G., K.M., G.D.) - both in San Francisco
| | - Lianne S Gensler
- From the Department of Medicine, University of California, San Francisco (A.R.L., L.S., L.S.G., K.M., G.D.), and the Medical Service, San Francisco Veterans Affairs Medical Center (L.S.G., K.M., G.D.) - both in San Francisco
| | - Kenneth McQuaid
- From the Department of Medicine, University of California, San Francisco (A.R.L., L.S., L.S.G., K.M., G.D.), and the Medical Service, San Francisco Veterans Affairs Medical Center (L.S.G., K.M., G.D.) - both in San Francisco
| | - Gurpreet Dhaliwal
- From the Department of Medicine, University of California, San Francisco (A.R.L., L.S., L.S.G., K.M., G.D.), and the Medical Service, San Francisco Veterans Affairs Medical Center (L.S.G., K.M., G.D.) - both in San Francisco
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17
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Tanigawa M, Kataoka Y, Kishino T, Kohama M, Uyama Y, Suzuki Y, Yokoi H. Identification of gastrointestinal perforation based on ICD-10 code in a Japanese administrative medical information database and associated drug exposure risk factors. Pharmacoepidemiol Drug Saf 2019; 28:976-984. [PMID: 31197887 DOI: 10.1002/pds.4837] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 05/09/2019] [Accepted: 05/10/2019] [Indexed: 12/29/2022]
Abstract
PURPOSE The purpose of this study is to evaluate the accuracy of gastrointestinal (GI) perforation ICD-10 coding in the Diagnosis Procedure Combination (DPC) database and to examine drug exposure risk factors for GI perforation. METHODS A total of 100 patients with GI perforation ICD-10 codes were selected randomly from Kagawa University Hospital's DPC database between April 2011 and December 2016. Two experienced specialist physicians independently reviewed the medical records and classified cases as "definite A," "definite B," "probable," or "no GI perforation." The positive predictive values (PPVs) of "definite A/B" cases were calculated after stratification by sex, age, ICD-10 code, and diagnostic information in the DPC data. The number of prescribed drugs with side effects of GI perforation according to historical data was compared between "definite A/B" and "no GI perforation" cases. RESULTS The overall PPV was 47.0% (95% confidence interval [CI], 36.9-57.2). However, the PPVs for the three categories of diagnostic information in the DPC data ("main diagnosis," "diagnosis causing admission," and "most resource-intensive diagnosis") were each more than 70% after excluding inappropriate patients. Additionally, the PPV focused on these three categories was 76.3% (95% CI, 59.8-88.6). Prescribed drugs with side effects of GI perforation were more frequently detected in "definite A/B" cases (P = .028). CONCLUSIONS Although the overall PPV for GI perforation based on ICD-10 code was low, our results suggest that the PPV could be improved by appropriate selection of DPC diagnosis category and that use of multiple medications enhances the risk of GI perforation.
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Affiliation(s)
- Masatoshi Tanigawa
- Department of Medical Informatics, Kagawa University Hospital, Kagawa, Japan
| | - Yoko Kataoka
- Department of Medical Informatics, Kagawa University Hospital, Kagawa, Japan
| | - Takayoshi Kishino
- Department of Gastrointestinal Surgery, Kagawa University Hospital, Kagawa, Japan
| | - Mei Kohama
- Office of Medical Informatics and Epidemiology, Pharmaceuticals and Medical Devices Agency, Tokyo, Japan
| | - Yoshiaki Uyama
- Office of Medical Informatics and Epidemiology, Pharmaceuticals and Medical Devices Agency, Tokyo, Japan
| | - Yasuyuki Suzuki
- Department of Gastrointestinal Surgery, Kagawa University Hospital, Kagawa, Japan
| | - Hideto Yokoi
- Department of Medical Informatics, Kagawa University Hospital, Kagawa, Japan
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18
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Maaser C, Sturm A, Vavricka SR, Kucharzik T, Fiorino G, Annese V, Calabrese E, Baumgart DC, Bettenworth D, Borralho Nunes P, Burisch J, Castiglione F, Eliakim R, Ellul P, González-Lama Y, Gordon H, Halligan S, Katsanos K, Kopylov U, Kotze PG, Krustinš E, Laghi A, Limdi JK, Rieder F, Rimola J, Taylor SA, Tolan D, van Rheenen P, Verstockt B, Stoker J. ECCO-ESGAR Guideline for Diagnostic Assessment in IBD Part 1: Initial diagnosis, monitoring of known IBD, detection of complications. J Crohns Colitis 2019; 13:144-164. [PMID: 30137275 DOI: 10.1093/ecco-jcc/jjy113] [Citation(s) in RCA: 909] [Impact Index Per Article: 181.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Christian Maaser
- Outpatients Department of Gastroenterology, Hospital Lüneburg, Lüneburg, Germany
| | - Andreas Sturm
- Department of Gastroenterology, DRK Kliniken Berlin I Westend, Berlin, Germany
| | | | - Torsten Kucharzik
- Department of Internal Medicine and Gastroenterology, Hospital Lüneburg, Lüneburg, Germany
| | - Gionata Fiorino
- Department of Gastroenterology, Humanitas Clinical and Research Institute, Milan, Italy
| | - Vito Annese
- Department of Gastroenterology, Valiant Clinic & American Hospital, Dubai, UAE
| | - Emma Calabrese
- Department of Systems Medicine, University of Rome, Tor Vergata, Italy
| | - Daniel C Baumgart
- Division of Gastroenterology, University of Alberta, Edmonton, AB, Canada
| | - Dominik Bettenworth
- Department of Medicine B, Gastroenterology and Hepatology, University Hospital Münster, Münster, Germany
| | - Paula Borralho Nunes
- Department of Anatomic Pathology, Hospital Cuf Descobertas; Faculdade de Medicina da Universidade de Lisboa, Lisbon, Portugal
| | - Johan Burisch
- Department of Gastroenterology, North Zealand University Hospital; Center for Clinical Research and Prevention, Bispebjerg and Frederiksberg Hospital, Frederiksberg, Denmark
| | - Fabiana Castiglione
- Department of Clinical Medicine and Surgery, "Federico II" University of Naples, Naples, Italy
| | - Rami Eliakim
- Department of Gastroenterology, Sheba Medical Center, Sackler School of Medicine, Tel Aviv, Israel
| | - Pierre Ellul
- Department of Medicine, Mater Dei Hospital, Msida, Malta
| | - Yago González-Lama
- Department of Gastroenterology, University Hospital Puerta De Hierro, Majadahonda [Madrid], Spain
| | - Hannah Gordon
- Department of Gastroenterology, Royal London Hospital, London, UK
| | - Steve Halligan
- Centre for Medical Imaging, University College London, London, UK
| | - Konstantinos Katsanos
- Department of Gastroenterology and Hepatology, University and Medical School of Ioannina, Ioannina, Greece
| | - Uri Kopylov
- Department of Gastroenterology, Sheba Medical Center, Sackler School of Medicine, Tel Aviv, Israel
| | - Paulo G Kotze
- Colorectal Surgery Unit, Catholic University of Paraná [PUCPR], Curitiba, Brazil
| | - Eduards Krustinš
- Department of of Gastroenterology, Hepatology and Nutrition, Pauls Stradins Clinical University Hospital, Riga, Latvia
| | - Andrea Laghi
- Department of Clinical and Surgical Translational Medicine, Sapienza University of Rome, Rome, Italy
| | - Jimmy K Limdi
- Department of Gastroenterology, Pennine Acute Hospitals NHS Trust, Manchester; Manchester Academic Health Sciences Centre, University of Manchester, UK
| | - Florian Rieder
- Department of Gastroenterology, Hepatology & Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Jordi Rimola
- Department of Radiology, Hospital Clínic Barcelona, Barcelona, Spain
| | - Stuart A Taylor
- Centre for Medical Imaging, University College London, London, UK
| | - Damian Tolan
- Clinical Radiology, St James's University Hospital, Leeds, UK
| | - Patrick van Rheenen
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, University Medical Center Groningen, Groningen, The Netherlands
| | - Bram Verstockt
- Department of Gastroenterology and Hepatology, University Hospitals Leuven and CHROMETA - Translational Research in Gastrointestinal Disorders, KU Leuven, Leuven, Belgium
| | - Jaap Stoker
- Department of Radiology and Nuclear Medicine, Academic Medical Center [AMC], University of Amsterdam, Amsterdam, The Netherlands
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19
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Frey A, Ramaker K, Röckendorf N, Wollenberg B, Lautenschläger I, Gébel G, Giemsa A, Heine M, Bargheer D, Nielsen P. Fate and Translocation of (Nano)Particulate Matter in the Gastrointestinal Tract. BIOLOGICAL RESPONSES TO NANOSCALE PARTICLES 2019. [DOI: 10.1007/978-3-030-12461-8_12] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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20
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Multiple spontaneous small bowel perforations due to clozapine-Case report. Int J Surg Case Rep 2018; 53:262-264. [PMID: 30447547 PMCID: PMC6240700 DOI: 10.1016/j.ijscr.2018.10.067] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Revised: 10/07/2018] [Accepted: 10/13/2018] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION Spontaneous free perforation of the small bowel is unusual. There are many causes of spontaneous small bowel free perforation such as: immune-mediated or inflammatory, infections, drugs and biological agents, congenital, metabolic, vascular and neoplasm. A severe adverse effect of antipsychotic drugs is intestinal ischemia, which could lead to perforation. CASE PRESENTATION The authors report the clinical case of a 42-year-old schizophrenic patient, smoker, medicated with clozapine 600 mg per day, admitted to the emergency room with diffuse abdominal pain. On physical examination the patient presented abdominal rebound tenderness and peritoneal sign with raised inflammation markers and the abdominal tomography revealed pneumoperitoneum. An emergency laparotomy revealed multiple jejunal and ileal perforations. The patient was subject to small bowel resection complicated with anastomosis dehiscence, respiratory tract infection and intra-abdominal abscess. Histologic specimens showed nonspecific inflammatory findings with ischemia. The main infectious, inflammatory, congenital, auto-immune and vascular causes of spontaneous perforations were excluded. DISCUSSION Spontaneous free perforation of the small bowel is uncommon. An intestinal ischemia might be a rare adverse effect of antipsychotics. However, only colon perforations due to ischemic colitis are described in the literature. While diagnosis of the precise cause might be challenging, and after excluding other causes, these perforations may be attributed to an adverse effect of clozapine. CONCLUSION The cause was attributed to clozapine as the other etiologies were excluded. The clozapine's reintroduction is controversial. In this case the clozapine dose was reduced successfully.
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21
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Singh RR, Nussbaum JS, Kumta NA. Endoscopic management of perforations, leaks and fistulas. Transl Gastroenterol Hepatol 2018; 3:85. [PMID: 30505972 DOI: 10.21037/tgh.2018.10.09] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2018] [Accepted: 10/19/2018] [Indexed: 12/14/2022] Open
Abstract
The endoscopic management armamentarium of gastrointestinal disruptions including perforations, leaks, and fistulas has slowly but steadily broadened in recent years. Previously limited to surgical or conservative medical management, innovations in advanced endoscopic techniques like natural orifice transluminal endoscopic surgery (NOTES) have paved the path towards development of endoscopic closure techniques. Early recognition of a gastrointestinal defect is the most important independent variable in determining successful endoscopic closure and patient outcome. Some devices including through the scope clips and stents have been well studied for other indications and have produced encouraging results in closure of gastrointestinal perforations, leaks and fistulas. Over the scope clips, endoscopic sutures, vacuum therapy, glue, and cardiac device occluders are other alternative techniques that can be employed for successful endoscopic closure.
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Affiliation(s)
- Ritu Raj Singh
- Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jeremy S Nussbaum
- Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Nikhil A Kumta
- Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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22
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Uzunoglu MY, Altintoprak F, Dikicier E, Zengin I. Treatment results of small bowel perforations due to unusual causes. Pak J Med Sci 2018; 34:974-979. [PMID: 30190764 PMCID: PMC6115567 DOI: 10.12669/pjms.344.14808] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Objectives: Although non-traumatic Small Bowel Perforations (SBPs) are rare, they have high rates of morbidity and mortality in case of late presentation. Aetiological factors vary across different geographical regions. In this paper, SBPs caused by anything other than trauma and other well-known causes are presented and the current literature is reviewed. Methods: The study was conducted at General Surgery Clinics of two different tertiary university hospitals between January 2008 and September 2016. The authors directly involved in managing the patients. This study was approved by the ethical institutional board and was performed at the Department of General Surgery, School of Medicine, Sakarya University. The medical records of patients retained in both hospitals are electronic. Medical records of subjects who had undergone emergency operations with a prediagnosis of acute abdomen in single center, and were determined to have SBPs due to unusual causes, were investigated retrospectively. Patients with aetiological factors such as trauma, mesenteric vascular disease, internal and external hernias, intra abdominal adhesions, inflammatory bowel diseases, and iatrogenic causes were excluded. Results: In total, 35 patients were evaluated, 20 (57.1%) males and 15 (42.9%) females. The mean age of the cases was 51.6 (18–88) years. Mean time until admission at the hospital was 1.4 days (range 0.25–7 days). The most frequent aetiological factors were various malignancies (10 cases, 28.5%) and perforation of Meckel’s diverticulum (8 cases, 22.8%). It was surprising to detect a considerable rate of perforation due to bezoars (6 patients, 17.1%). Conclusions: Post-operative consequences of SBPs due to unusual causes are similar with those related to common, known causes. Factors affecting the clinical course are presentation time and patients’ clinical status in admission, not aetiology.
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Affiliation(s)
- Mustafa Yener Uzunoglu
- Mustafa Yener Uzunoglu, MD. Department of General Surgery, Sakarya University, Research and Educational Hospital, Sakarya, Turkey
| | - Fatih Altintoprak
- Fatih Altintoprak, MD. Department of General Surgery, Istinye University Faculty of Medicine, Istanbul, Turkey. Department of General Surgery, Sakarya University, Research and Educational Hospital, Sakarya, Turkey
| | - Enis Dikicier
- Enis Dikicier, MD. Istinye University Faculty of Medicine, Istanbul, Turkey
| | - Ismail Zengin
- Ismail Zengin, MD. Department of General Surgery, Sakarya University, Research and Educational Hospital, Sakarya, Turkey
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23
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Amorosi V, Longo B, Sorotos M, Firmani G, D'Angelo F, Santanelli di Pompeo F. Intestinal perforation after surgical treatment for incisional hernia: iatrogenic or idiopathic? CASE REPORTS IN PLASTIC SURGERY AND HAND SURGERY 2018; 5:18-22. [PMID: 29707608 PMCID: PMC5917326 DOI: 10.1080/23320885.2018.1446044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Accepted: 02/24/2018] [Indexed: 11/21/2022]
Abstract
Intestinal perforation (IP) is a life-threatening gastroenterological condition requiring urgent surgical care, which may present itself as an uncommon complication following incisional hernia repair surgery, most often because of iatrogenic traumatism occurring during the procedure. However, we report a case where a spontaneous onset can be hypothesised. A 60-years-old patient underwent repair of an abdominal laparocele, through rectus abdominis muscle plasty, 5 years after development of an incisional hernia due to exploratory laparotomy for the treatment of acute appendicitis. Xipho-pubic scar was excised and umbilicus and supra-umbilical hernia sac dissected, a linear median incision was performed along the sub-umbilical linea alba, reaching preperitoneal plane to assess any intestinal loop adherence to the abdominal wall. After limited viscerolysis, abdominal wall defect was corrected by ‘rectus abdominis muscle plasty’ and umbilicus reconstruction by Santanelli technique. Postoperative course was uneventful until Day 29, with sudden onset of epigastric pain, fever and bulge. Sixty cubic centimeter pus was drained percutaneously and cavity was rinsed with a 50% H2O2 and H2O V-V solution until draining clear fluid. Symptoms recurred two days later, while during rinsing presented dyspnoea. X-Ray and CT scan diagnosed IP, and she underwent under emergency an exploratory laparotomy, leading to right hemicolectomy extended to last ileal loops and middle third of the transverse, right monolateral salpingo-ovariectomy and a temporary ileostomy by general surgeon. Twenty-three days later an ileostomy reversal surgery was performed and 8 days after she was discharged. At latest follow-up patient showed fair conditions, complaining abdominal pain and diarrhoea, attributable to the extensive intestinal resection. IP following incisional hernia repair, is reported as uncommon and early postoperative complication. In our case, the previous regular postoperative course with late onset lead us to hypothesise a possible idiopathic etiopathogenesis, because of a strangulation followed by gangrene and abscess formation, which might begin before the incisional hernia repair and unnoticed at the time surgery was performed.
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Affiliation(s)
- V Amorosi
- Plastic Surgery Unit, Sant'Andrea Hospital, School of Medicine and Psychology, 'Sapienza' University of Rome, Rome, Italy
| | - B Longo
- Plastic Surgery Unit, Sant'Andrea Hospital, School of Medicine and Psychology, 'Sapienza' University of Rome, Rome, Italy
| | - M Sorotos
- Plastic Surgery Unit, Sant'Andrea Hospital, School of Medicine and Psychology, 'Sapienza' University of Rome, Rome, Italy
| | - G Firmani
- School of Medicine and Psychology, 'Sapienza' University of Rome, Rome, Italy
| | - F D'Angelo
- General Surgery Unit, Sant'Andrea Hospital, School of Medicine and Psychology, 'Sapienza' University of Rome, Rome, Italy
| | - F Santanelli di Pompeo
- Plastic Surgery Unit, Sant'Andrea Hospital, School of Medicine and Psychology, 'Sapienza' University of Rome, Rome, Italy
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Thilakawardana BU, De Mel S, Abeysuriya V, Hewavisenthi J, De Mel C, Chandrasena L, Abeysuriya V. A rare presentation of an acute abdomen: an ileal diverticular perforation. BMC Res Notes 2017; 10:190. [PMID: 28578700 PMCID: PMC5457724 DOI: 10.1186/s13104-017-2514-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Accepted: 05/26/2017] [Indexed: 11/21/2022] Open
Abstract
Background This case report highlights the value of prompt intervention of diagnostic laparoscopy in a patient suspects of having an acute abdomen due to an intestinal perforation, where there is a limitation of performing Contrast Enhanced Computed Tomography of abdomen. A previously healthy young adult presenting with an acute abdomen due to a spontaneous ileal perforation, without any associated risk factors is a rare clinical entity in a developing country. Therefore, entertaining an early diagnosis will possibly prevent a fatal consequence. Case presentation A male patient, 29 years old, recently diagnosed as a young hypertensive without any associated factors, currently on antihypertensive treatment, was admitted to our hospital presenting with an acute severe abdominal pain. During initial assessment, the patient was febrile (101 °F), ill looking, tachycardic (pulse rate 121 bpm) with rapid shallow breathing. Abdominal examination reviled diffuse guarding and rigidity, more severe on right iliac fossa. Following history and clinical examination probable clinical diagnosis was made as an acute appendicitis with perforation. However, ultrasonography was found to have normal appendix. Contrast Enhanced Computed Tomography was not performed as a subsequent investigation because of the impairment of renal functions of this patient. Though, non-contrast CT would have been ascertained more diagnostic yield, given the critically ill status of this patient we decided to perform urgent diagnostic laparoscopy. It reviled pus in several abdominal cavities and dense adhesions. Therefore, the procedure was converted to a laparotomy and found to have an ileal perforation with diffuse peritoneal contamination. Diseased ileal segment was resected and anastomosed. Followed by peritoneal lavage. Conclusion Ileal perforation due to diverticular disease in a healthy young adult is rare. This case report highlights the importance of considering this clinical entity as a differential diagnosis, the value of early diagnostic laparoscopy, especially in clinical settings with limitations to CT scan, since late diagnosis can give rise to fatal outcome.
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Affiliation(s)
- Basuru Uvindu Thilakawardana
- Nawaloka Hospitals Research and Educational Centre, Nawaloka Hospitals PLC, No. 23, Deshamanya H.K. Dharmadasa Mw, Colombo 02, Sri Lanka.
| | - Sanjay De Mel
- Nawaloka Hospitals Research and Educational Centre, Nawaloka Hospitals PLC, No. 23, Deshamanya H.K. Dharmadasa Mw, Colombo 02, Sri Lanka
| | | | | | - Chandima De Mel
- Nawaloka Hospitals Research and Educational Centre, Nawaloka Hospitals PLC, No. 23, Deshamanya H.K. Dharmadasa Mw, Colombo 02, Sri Lanka
| | - Lal Chandrasena
- Nawaloka Hospitals Research and Educational Centre, Nawaloka Hospitals PLC, No. 23, Deshamanya H.K. Dharmadasa Mw, Colombo 02, Sri Lanka
| | - Visula Abeysuriya
- Nawaloka Hospitals Research and Educational Centre, Nawaloka Hospitals PLC, No. 23, Deshamanya H.K. Dharmadasa Mw, Colombo 02, Sri Lanka
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Gutiérrez-Delgado EM, Villanueva-Lozano H, García Rojas-Acosta MJ, Miranda-Maldonado IC, Ramos-Jiménez J. A case report of small bowel perforation secondary to cytomegalovirus related immune reconstitution inflammatory syndrome in an AIDS patient. Ann Med Surg (Lond) 2017; 13:20-23. [PMID: 28018589 PMCID: PMC5176126 DOI: 10.1016/j.amsu.2016.11.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2016] [Revised: 11/06/2016] [Accepted: 11/06/2016] [Indexed: 12/27/2022] Open
Abstract
Non-traumatic small bowel perforation is rare in adults but carries a high morbidity and mortality. The diagnosis is made on clinical suspicion, and the most common causes in developing countries are infectious diseases, being cytomegalovirus infection in immunocompromised patients the main etiology. We describe a patient with a recently diagnosed advanced stage HIV infection and an intestinal perforation associated with cytomegalovirus immune reconstitution inflammatory syndrome after highly active antiretroviral therapy initiation.
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Affiliation(s)
- Eva María Gutiérrez-Delgado
- Infectious Diseases Service, Internal Medicine Department, Hospital Universitario “Dr. José Eleuterio González”, Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - Hiram Villanueva-Lozano
- Infectious Diseases Service, Internal Medicine Department, Hospital Universitario “Dr. José Eleuterio González”, Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | | | - Ivett C. Miranda-Maldonado
- Department of Pathological Anatomy and Cytopathology, Hospital Universitario “Dr. José Eleuterio González”, Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - Javier Ramos-Jiménez
- Infectious Diseases Service, Internal Medicine Department, Hospital Universitario “Dr. José Eleuterio González”, Universidad Autónoma de Nuevo León, Monterrey, Mexico
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Żyluk AŻ, Szlosser Z. Perforation of the Peptic Ulcer Localized in the Proximal Jejunum - Case Report. POLISH JOURNAL OF SURGERY 2016; 88:215-7. [PMID: 27648623 DOI: 10.1515/pjs-2016-0054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Indexed: 11/15/2022]
Abstract
Non-traumatic perforation of the digestive tract occurs most often in the duodenum and stomach (peptic ulcer), as well as the colon (diverticulitis, cancer or ischemic lesions). Perforation of the small bowel is very rare. The Authors of the study presented a case of proximal jejunum perforation, which occurred in a patient with a history of duodenal peptic ulcer disease. Diagnosis posed no difficulties, and treatment included the excision of the ulceration and suturing of the bowel. The patient recovered without complications and the histological examination failed to reveal the nature of the ulcer. However, based on the medical history, one may suppose that it might be of peptic etiology, which makes this case exceptional.
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Pollard C, Fransman RB, Jessie TA, Gurfinchel G. Spontaneous seromuscular laceration of the sigmoid colon: a case report. Clin Case Rep 2016; 3:1007-11. [PMID: 26733085 PMCID: PMC4693696 DOI: 10.1002/ccr3.396] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2015] [Revised: 07/26/2015] [Accepted: 08/23/2015] [Indexed: 01/21/2023] Open
Abstract
Injury to bowel can result in high morbidity and death. Bowel injuries typically occur after external trauma to the abdomen. Bowel injury in the absence of external trauma is rare. Here, we report a 36‐year‐old male presenting with a sigmoid colon laceration likely due to long‐standing constipation.
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Affiliation(s)
- Courtney Pollard
- Department of Internal Medicine Medstar Harbor Hospital Baltimore Maryland USA
| | - Ryan B Fransman
- Department of Internal Medicine Medstar Harbor Hospital Baltimore Maryland USA
| | - Timothy A Jessie
- Department of Surgery Medstar Harbor Hospital Baltimore Maryland USA
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Luglio G, De Palma GD, Liccardo F, Giglio MC, Sollazzo V, Zito G, Bucci L. Recurrent, spontaneous, postoperative small bowel perforations caused by invasive candidiasis. Int J Colorectal Dis 2015; 30:1585-6. [PMID: 25735924 DOI: 10.1007/s00384-015-2138-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/21/2015] [Indexed: 02/04/2023]
Affiliation(s)
- Gaetano Luglio
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy.
| | | | - Filomena Liccardo
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Mariano Cesare Giglio
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Viviana Sollazzo
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Geremia Zito
- Department of Neurosciences, Reproductive and Odontostomatologic Sciences, University of Naples Federico II, Naples, Italy
| | - Luigi Bucci
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
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Kok-Hong Chan D, Lee KC. Perforated Intestinal Tuberculosis in a Non-AIDS Immunocompromised Patient. AMERICAN JOURNAL OF CASE REPORTS 2015; 16:719-22. [PMID: 26451879 PMCID: PMC4603593 DOI: 10.12659/ajcr.894723] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Patient: Male, 68 Final Diagnosis: Intestinal perforation Symptoms: Abdominal pain Medication: — Clinical Procedure: Exploratory laparotomy and bowel resection Specialty: Surgery
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Affiliation(s)
- Dedrick Kok-Hong Chan
- Division of Colorectal Surgery, University Surgical Cluster, National University Health System, Singapore, Singapore
| | - Kuok-Chung Lee
- Division of Colorectal Surgery, University Surgical Cluster, National University Health System, Singapore, Singapore
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Pneumatosis Intestinalis in a Patient with Acute Promyelocytic Leukemia. Case Rep Hematol 2015; 2015:576042. [PMID: 26635981 PMCID: PMC4618106 DOI: 10.1155/2015/576042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Accepted: 09/20/2015] [Indexed: 11/17/2022] Open
Abstract
Pneumatosis Intestinalis is a rare condition characterized by the presence of gas within the intestinal wall. We describe a case of a 33-year-old woman with acute promyelocytic leukemia who developed nausea and nonbloody diarrhea. CT showed intramural air in transverse and descending colon. Patient clinically improved with conservative management.
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