Spontaneous Perforation Of Meckel's Diverticulum Presenting With Generalized Peritonitis

Meckel's diverticulum is the most common congenital anomaly of the GIT with a low incidence of 2% and the complication rate is even lower with perforation being the rarest. We report an intriguing case of a 15-year-old male, who presented with one-week history of high-grade fever and diarrhoea followed by acute onset of abdominal pain in the periumbilical region which became generalized. On physical examination his abdomen was distended with guarding and rigidity. A provisional diagnosis of peritonitis secondary to enteric perforation was made and exploratory laparotomy was done which revealed a perforated Meckel's diverticulum and advanced peritonitis. A diverticulectomy with double barrel ileostomy were performed. No heterotopic tissue in the diverticulum was noted on histopathology, nor any other abnormal tissue identified. The patient made an uneventful recovery postoperatively and ileostomy reconstruction was done two months later. This case report is rare case of Meckel's diverticulum complications and highlights the importance of considering Meckel's diverticulum as a differential diagnosis in every patient presenting with acute abdomen, which can aid toward better management through laparoscopy.

Histopathological findings in a COVID-19 patient affected by ischemic gangrenous cholecystitis

BACKGROUND

Since its first documentation, a novel coronavirus (SARS-CoV-2) infection has emerged worldwide, with the consequent declaration of a pandemic disease (COVID-19). Severe forms of acute respiratory failure can develop. In addition, SARS-CoV-2 may affect organs other than the lung, such as the liver, with frequent onset of late cholestasis. We here report the histological findings of a COVID-19 patient, affected by a tardive complication of acute ischemic and gangrenous cholecystitis with a perforated and relaxed gallbladder needing urgent surgery.

CASE PRESENTATION

A 59-year-old Caucasian male, affected by acute respiratory failure secondary to SARS-CoV-2 infection was admitted to our intensive care unit (ICU). Due to the severity of the disease, invasive mechanical ventilation was instituted and SARS-CoV-2 treatment (azithromycin 250 mg once-daily and hydroxychloroquine 200 mg trice-daily) started. Enoxaparin 8000 IU twice-daily was also administered subcutaneously. At day 8 of ICU admission, the clinical condition improved and patient was extubated. At day 32, patient revealed abdominal pain without signs of peritonism at examination, with increased inflammatory and cholestasis indexes at blood tests. At a first abdominal CT scan, perihepatic effusion and a relaxed gallbladder with dense content were detected. The surgeon decided to wait and see the evolution of clinical conditions. The day after, conditions further worsened and a laparotomic cholecystectomy was performed. A relaxed and perforated ischemic gangrenous gallbladder, with a local tissue inflammation and perihepatic fluid, was intraoperatively met. The gallbladder and a sample of omentum, adherent to the gallbladder, were also sent for histological examination. Hematoxylin-eosin-stained slides display inflammatory infiltration and endoluminal obliteration of vessels, with wall breakthrough, hemorrhagic infarction, and nerve hypertrophy of the gallbladder. The mucosa of the gallbladder appears also atrophic. Omentum vessels also appear largely thrombosed. Immunohistochemistry demonstrates an endothelial overexpression of medium-size vessels (anti-CD31), while not in micro-vessels, with a remarkable activity of macrophages (anti-CD68) and T helper lymphocytes (anti-CD4) against gallbladder vessels. All these findings define a histological diagnosis of vasculitis of the gallbladder.

CONCLUSIONS

Ischemic gangrenous cholecystitis can be a tardive complication of COVID-19, and it is characterized by a dysregulated host inflammatory response and thrombosis of medium-size vessels.

Adaptive process triage system cannot identify patients with gastrointestinal perforation

INTRODUCTION

Adaptive process triage (ADAPT) is a triage tool developed to assess the severity and address the priority of emergency patients. In 2009-2011, ADAPT was the most frequently used triage system in Denmark. Until now, no Danish triage system has been evaluated based on a selective group of patients in need of acute abdominal surgery. Gastrointestinal perforation (GIP) is acknowledged as one of the surgical conditions with the highest mortality rates. The aim of this study was to evaluate whether ADAPT can identify patients with GIP.

METHODS

All abdominal emergency laparoscopies and laparotomies performed over a one-year period at Herlev Hospital, Denmark, were included. Patient data and triage levels were collected from medical records. We defined patients suspected of less severe surgical illness as green-yellow and patients suspected of severe/life-threatening illness as orange-red.

RESULTS

A total of 803 patients with a known triage level were identified: 47% green, 38% yellow, 13% orange and 2% red. Of these patients, 136 were identified with a GIP. The negative predictive value was 83.2% (95% confidence interval: 80.1-85.7), meaning that one out of six abdominal surgery patients triaged as green or yellow had a GIP that was not identified by the triage system.

CONCLUSION

ADAPT is incapable of identifying one of the most critically ill patient groups in need of emergency abdominal surgery.

FUNDING

none.

TRIAL REGISTRATION

HEH-2013-034 I-Suite: 02336.

[Perforated gastric non-Hodgkin lymphoma]

Lymphomas are solid tumors of the lymphatic system and these are divided into Hodgkin's and non-Hodgkin lymphoma. Non-Hodgkin tumors may originate from non-nodal tissues such as the gastrointestinal tract and they are considered primary when extranodal involvement is equal to or greater than 75% according to the nodal involvement. Extranodal gastrointestinal lymphomas represent 1% to 4% of tumors of the digestive tract, and 10 to 15% of all non-Hodgkin lymphomas. The stomach is the most common extranodal lymphomas site. We present the clinical case of a sexagenarian male natural of Chiclayo who had an upper GI endoscopy for non-specific symptoms of dyspepsia that only reports gastritis and when admitted to our institution is diagnosed by endoscopy, biochemical markers and pathology as a perforated gastric non-Hodgkin lynphoma.

Congenital diaphragmatic eventration complicated with neonatal gastric perforation

Congenital diaphragm eventration is a rare and usually asymptomatic developmental defect. Neonatal gastric perforation is also a rare but lifethreatening condition. In our knowledge, the association of these two pathologies has been, exceptionally reported. We report a case who illustrates clinical and radiological features of this possible co-morbidity. A full-term male neonate was born from uneventful pregnancy and delivery. The antenatal scan was reported as normal. At birth, clinical exam was normal, no special resuscitation was necessary. The newborn was examined and admitted the 4th day of life for fever, tachypnea, cyanosis, hemodynamic shock and refusing feeds. Clinical examination suggested peritonitis. Chest radiography and ultrasonography suggested congenital hernia. A laparotomy was performed after a brief resuscitation and confirmed the presence of diaphragm eventration with gastric perforation. Suturing of gastric perforation with a diaphragmatic plication was performed with favorable evolution.

[Spontaneous perforation of the bile duct in a neonate: An unexpected finding. Case report]

Spontaneous extrahepatic bile duct perforation is rare in newborns. It is a surgical cause of jaundice in this period and the acute presentation is unusual.

OBJECTIVE

To report a case of spontaneous bile duct perforation in a newborn due to its serious complications if an early and timely diagnosis is not performed.

CLINICAL CASE

A 10-day-old newborn who developed food rejection, fever and abdominal distension without jaundice, acolia, or coluria two days prior of admission. The laboratory tests showed leukopenia, thrombocytosis, increased C-reactive protein, and normal hepatic function. The abdominal x-ray showed pneumoperitoneum, and the diagnosis of necrotizing enterocolitis was made. Laparotomy was performed; extrahepatic bile duct perforation and biliary peritonitis were noted. Intraoperative cholangiography demonstrated rescatable proximal bile duct and dilated cystic duct. Hepatic-jejunostomy was performed with Roux-en-Y and cholecystectomy. In the postoperative study portal thrombosis was found, so he received anticoagulant treatment. At 8 months of age, the patient had enteral feeding tolerance and adequate weight gain.

CONCLUSIONS

Biliary perforation is a rare entity and more in the neonatal period, a condition that makes it a diagnostic and therapeutic challenge. The prognosis will depend on early intervention and intraoperative findings.

Thoracic spinal epidural abscess caused by fishbone perforation: A case report and review of literature

RATIONALE

Ingestion of a fishbone is a common cause of esophageal injury, but spinal epidural abscess (SEA) is a rare condition due to the esophageal penetration by a swallowed fishbone. Prompt diagnosis can be seldom made owing to incomplete patient history taking and difficulties in imaging evidence identification.

PATIENT CONCERNS

We describe the case of a 62-year-old woman who was stuck in her throat by a fishbone, and complained of back pain, paresis of the lower limbs and fever, successively. To our knowledge, this is the first case report that we know of thoracic SEA caused by fishbone perforation.

DIAGNOSES

About 20 days after the onset of severe back pain, she was diagnosed with SEA based on the clinical presentation and imaging findings.

INTERVENTIONS

Antibiotic therapy and rehabilitation therapy were carried out afterwards. However, due to exacerbation of her condition, surgical intervention had to be taken eventually.

OUTCOMES

It is quite unfortunate for this patient to have a poor prognosis due to a delayed diagnosis and an improper management.

LESSONS

A number of lessons can be learnt from this case.

Spontaneous Perforation Of Bile Duct, Clinical Presentation, Laboratory Work Up, Treatment And Outcome

BACKGROUND

Spontaneous perforation of bile duct (SPBD) is a rare and often misdiagnosed entity. Though rare, it is the second most common surgical cause of jaundice in infants, after biliary atresia. This study was planned to determine the clinical presentation, study different diagnostic modalities, treatment and outcome of patients with spontaneous perforation of bile duct.

METHODS

This descriptive case series, comprising 22 patients with spontaneous perforation of bile duct over a period of 24 months. Clinical presentation, biochemical abnormalities, imaging details, treatment options and outcome were studied.

RESULTS

Total 22 patients (12 Males and 10 Females) between ages of 1.5-36 months were studied. Associated anatomical defects included choledochal cyst in 7 (31.8%) while acquired biliary atresia in 1 (4.5%). Elevated liver enzymes (ALT and AST) were present in 16 patients (72.7%) and 5 (22.7%) had bilirubin above 3 mg/dl. Coagulopathy was seen in 8 (36.6%) patients. Abdominal USG showed presence of ascites in all 22 (100%), hydrocele in 2 (9.0%), inguinal hernia in 1 (4.5%), choledochal cyst in 7 (31.8%) and atretic gall bladder suggestive of acquired biliary atresia in one (4.5%) patient. HIDA scan was diagnostic in all 17 (77.27%) in which it was performed. MRCP was done in 3 (13.6%) patients. Mortality frequency was 3/22 (13.6%); one died of post-surgical sepsis second one was cirrhotic at time of presentation and didn't make It. Two were lost to follow up one which died at home while we lost contact with fourth patient.

CONCLUSIONS

Spontaneous perforation of bile duct can present and should be suspected as an important cause of neonatal biliary ascites or peritonitis. Most patients can be managed with intravenous antibiotics, percutaneous drainage and ttube insertion while patients with choledochal cysts required cholecystectomy with roux en y choledochjejunostomy. Timely recognition and intervention is associated with favourable outcome.