Perforation Of Alimentary Tract Research Articles

The Impact of Delayed Surgical Care on Patient Outcomes With Alimentary Tract Perforation: Insight From a Low-Middle Income Country.

IntroductionIn-patient delay is associated with increased mortality in patients with alimentary tract perforations. Access to surgical care is a glaring health issue in low-middle income countries (LMICs), where patient presentation is also delayed for a myriad of reasons, which can be broadly categorized as social/cultural, financial, and structural in their nature. The impact these delays have on surgical outcomes in low-middle income countries is not known.MethodsA retrospective cohort study of patients who underwent emergency laparotomy for alimentary tract perforation from July 2015 to June 2018 was conducted at a tertiary care hospital in Karachi, Pakistan. Time was recorded in two variables: symptom onset to emergency room presentation (ERT) and emergency room to operation room time (ORT).ResultsOverall, 80 patients were included in the study. The 12 (15%) patients who expired were significantly older (57 ± 17.7 years of age), had a higher Charlson Comorbidity Index and had longer ORT [median ORT in hours-discharged vs expired: 8.2 (IQR 5-15) vs 16 (IQR 12-28) p=0.02]. ERT was also longer but lacked statistical significance [median ERT in hours-discharged vs expired: 24 (IQR 22-72) vs 48 (IQR 24-120) p=0.19]. Multivariable logistic regression analysis revealed ORT to be significantly associated with mortality [odds ratio (OR): 1.02, 95% confidence interval (CI): 1.003-1.041; p=0.02]. Adjusted Cox regression analysis showed that each hour of ORT increased the risk of mortality by 1.5% [hazard ratio (HR) 1.015, 95% CI 1.001-1.030].ConclusionInpatient delays increased the risk of mortality for patients undergoing emergency laparotomy for alimentary tract perforation. Larger sample sizes and prospective studies are needed to better understand this relationship and the impact pre-hospital delays have on outcomes.

Do Delays in Surgical Care Impact Outcomes in Patients with Alimentary Tract Perforation? View from a Low- to Middle-Income Country

Khan, Muhammad Sohaib MBBS; Ahmed, Shayan MBBS; Zafar, Muhammad H. MBBS; Zaka-ur-Rehman, Taha A. MBBS; Shariff, Amir H. MBBS, FACS Author Information

A Non-Surgical Condition of Neonatal Pneumoperitoneum: Retroperitoneal Free Air Secondary to Massive Tension Pneumothorax

Pneumoperitoneum in newborns is usually an emergent surgical condition which indicates alimentary tract perforation and therefore threatens the life. However, there are some non-surgical conditions causing pneumoperitoneum which do not require the explorative laparotomy. This report describes a rare case of neonate with pneumoperitoneum developed secondary to massive tension pneumothorax. Resolution of the free air in the retroperitoneal space was observed after tube thoracostomy. This case report suggests that massive tension pneumothorax can be a rare cause of non-surgical pneumoperitoneum. J Med Cases. 2016;7(1):13-14 doi: http://dx.doi.org/10.14740/jmc2371w

Imaging Patients With Alimentary Tract Perforation: Literature Review

Alimentary tract perforation is a frequent emergency condition. Imaging plays an important role to make an accurate diagnosis, defining the presence, the level, and the cause of the perforation, essential information to enable the most correct therapeutic choice. Plain radiography is generally performed as the first choice. In case of a clinically suspected bowel perforation, not detected on x-ray imaging, the contribution of computed tomography is essential. Magnetic resonance is not yet widely used in diagnostic workup of patients with acute abdominal pain, but it can be useful in the differential diagnosis of acute abdomen in specific patients (pregnancy and pediatric patients).

From esophagus to rectum: a comprehensive review of alimentary tract perforations at computed tomography

Gastrointestinal (GI) tract perforation is a life-threatening condition that can occur at any site along the alimentary tract. Early perforation detection and intervention significantly improves patient outcome. With a high sensitivity for pneumoperitoneum, computed tomography (CT) is widely accepted as the diagnostic modality of choice when a perforated hollow viscus is suspected. While confirming the presence of a perforation is critical, clinical management and surgical technique also depend on localizing the perforation site. CT is accurate in detecting the site of perforation, with segmental bowel wall thickening, focal bowel wall defect, or bubbles of extraluminal gas concentrated in close proximity to the bowel wall shown to be the most specific findings. In this article, we will present the causes for perforation at each site throughout the GI tract and review the patterns that can lead to prospective diagnosis and perforation site localization utilizing CT images of surgically proven cases.

Duodenal perforation in a patient with non-small cell lung cancer receiving Pemetrexed-Cisplatin combination.

Pemetrexed is increasingly used in combination with platinum antineoplastic agents for the treatment of certain lung malignancies. Its use was associated with favorable hematological adverse reaction compared to standard regimens. Non-hematological life-threatening complications such as gastrointestinal perforations are extremely rare with pemetrexed use and tend to develop in the distal bowel in patients at risk.We report the case of a 56-years old Arab male, heavy smoker newly diagnosed with Stage IV non-small cell lung cancer with no comorbidities, treated with pemetrexed-cisplatin combination. Four days after the first cycle of chemotherapy, the patient developed a small duodenal perforation that required emergency laparoscopy repair.Clinicians should have a high index of suspicion should be taken for alimentary tract perforation in patients presenting with acute abdominal pain during pemetrexed therapy.

Pneumoperitoneum following blunt abdominal injury: Does it warrant laparotomy?

Introduction: Intraabdominal injury causes significant morbidity and mortality. Pneumoperitoneum is normally associated with traumatic abdominal injuries. Generally, explorative laparotomy is indicated as part of management in the presence of pneumoperitoneum associated with intraabdominal injury. Case Report: We describe a case of suspected perforated intraabdominal viscus in a ventilated patient based on the presence of air under right diaphragm from chest radiography and the presence of pneumperitoneum from the Computed tomography (CT) scan of the abdomen. The laparotomy revealed intact gastrointestinal (GI) tract and absence of focal injury. Discussion: Radiological finding of air under diaphragm in a patient with pneumothorax or ventilated patient with absence of peritonism needs to be interpreted cautiously. Free intraperitoneal air is not necessarily caused by alimentary tract perforation. Other clinical conditions that may mimic pneumoperitoneum include Chilaiditi syndrome, basal lung bulla, undulating diaphragm, subphrenic abscess due to gas forming organisms, pyonephrosis due to gas forming organisms, subphrenic fat and pneumoretroperitoneum. In such patient, a diagnostic peritoneal lavage (DPL) using Otomo’s criteria and cell count ratio is highly predictive of the presence of blunt hollow visceral injury. Conclusion: A diagnostic peritoneal lavage (DPL) after CT scan of abdomen for identifying blunt hollow visceral injury is recommended. The combined application of the two criteria improves the accuracy of diagnosing blunt hollow visceral injury. Appropriate diagnosis prevents unnecessary invasive procedure.

消化管穿孔の診断におけるＣＴの有用性に関する検討

消化管穿孔の診断におけるＣＴの有用性に関する検討

ALIMENTARY TRACT PERFORATION AFTER LIVER TRANSPLANTATION IN CHILDREN.

A229 Alimentary tract perforation is well-recognized devastating entity that complicates up to 20 % of pediatric liver transplantation (LTx). Aims of the study are to assess the incidence, risk factors, treatment and outcome of alimentary tract perforation after pediatric LTx. Methods: 198 LTx in 182 patients were performed since 1990 to 2003 in our institution. There were 46 living related LTx, nine combined liver and kidney, and one liver and bowel transplantation. Patients older than 18 years old, and those who died before one month after LTx were excluded from further analysis. Children were classified into two groups: with (group I – 10) and without perforation (group II – 146). Age, body weight, UNOS status, previous surgery, duration of hepatectomy and unhepatic phase, blood transfusion during transplantation were retrospectively analyzed. The incidence of portal vein thrombosis, bacterial, fungal, and CMV infections, intensive steroid therapy because of acute rejection were assessed during the first posttransplant month. Results were statistically analyzed using Mann-Whitney, chi2, and t- test. Results: Alimentary tract perforations were diagnosed in 10 children (6,4%), including two who reperforated. Age of patients was between 7 months and 17 years. Indication for LTx in 8 children was biliary atresia, liver fibrosis - 1, cirrhosis of unknown etiology - 1. In three children perforations occurred after retransplantation. The interval between transplantation and perforation was from 6 to 22 days. Perforations were localized in: colon - 6 cases, jejunum - 5, duodenum - 3, stomach – 1. Two children developed recurrent perforations, one of them multifocal. The surgery of perforations consisted of: simple suture in 13 cases, resection and primary anastomosis – 1, ileostomy - 1. One patient died on 5th day after perforation and on 20th day after retransplantation due to multiorgan failure. The follow up of remaining nine patients is between 4 and 147 months. The incidence of perforation was higher (p < 0.05) after pretransplant laparotomy (especially Kasai procedure), and after retransplantation. Patients who perforated required more blood transfusions during LTx (p < 0.05). Between LTx and alimentary tract perforation they developed more frequently (p < 0.05) sever bacterial bowel infections in comparison to non-perforated group. There was no significant differences regarding: age, body weight, UNOS status, portal vein thrombosis, intensive steroid therapy, fungal infection, bacterial sepsis and CMV infection. The duration of hepatectomy and unhepatic phase were longer (not significantly) in the group of alimentary tract perforation. Conclusions: Alimentary tract perforations after pediatric LTx are related to pretransplant surgery (especially Kasai procedure), retransplantation, greater blood transfusions during LTx, and severe bacterial postransplant bowel infections. The mortality of alimentary tract perforation after pediatric LTx is low.

Perforation of Alimentary Tract in Neonate:Radiologic Findings,Causes and Prediction of Prognosis

目的 深入了解新生儿消化道穿孔X线表现,并对发病部位与发病原因及预后评估进行探讨.方法对照分析了24例临床手术资料与X线征象.结果各种位置X线检查发现气腹23例,大量气腹7例,中量气腹11例,少量气腹5例.气腹的X线征象除膈下游离气体外,在卧位或水平侧位片还可见足球征13例,镰状韧带征12例,铅笔征或Rigler氏征10例,黑三角征3例.气腹以外的其它征象是:胃泡影消失6例,肠管少气11例,肠管充气增多12例,肠管无气1例,肠间隙增宽12例,肠壁积气5例,腹腔液体增多15例,外围肠管可见气粪混合征3例.肠穿孔原因:胃壁先天性肌层缺损5例,各种先天性小肠畸形6例,结肠和直肠畸形4例,坏死性小肠结肠炎7例,胎粪性腹膜炎1例.结论 X线检查仍然是发现新生儿消化道穿孔的重要首选方法,对穿孔的原因和预后评估有一定帮助。

Perforation of the alimentary tract: evaluation with computed tomography.

To assess the value of computed tomography (CT) in the diagnosis of perforation of the alimentary tract (AT). During a 4-year period 76 patients with proven AT perforation underwent CT within 1 week before surgery or endoscopy. We retrospectively reviewed these CT scans to determine the signs of AT perforation. There were 41 men and 35 women (28-90 years old). Our goal was to establish the diagnosis of AT perforation and, if this was possible, to identify the site and cause of the AT wall rupture. The CT diagnosis of perforation was based on (a) direct findings of extraluminar air or gastrografin and (b) indirect findings of an abscess or an inflammatory mass surrounding an enterolith in the region of appendix or a bowel wall-related phlegmon or abscess with fluid in the mesentery or surrounding radiopaque foreign body. There were 65 true-positive and 11 false-negative cases. Levels of perforation were the esophagus (two), stomach (five), duodenum (12), small bowel (15), appendix (six), and colon (36). Causes were peptic ulcer (11), foreign body (five), trauma (seven), iatrogenic (nine), appendicitis (six), diverticulitis (21), Crohn disease (five), AT carcinoma (eight), and ischemia (four). Level and cause were correctly predicted in 55 and 51 instances, respectively. The sensitivity was estimated to 85.5%. CT is a valuable method in the diagnosis of AT perforation. The diagnosis can be established rapidly, without patient preparation and with a high sensitivity.

Traumatic injuries of the alimentary tract in children.

Traumatic alimentary tract (AT) perforations in children secondary to instrumentation, though rare, can occur at any age, especially in neonates and young infants. Awareness of such a possibility is essential for prompt management to be initiated. Over a 10-year period (1986-1995), eight pediatric patients with AT perforations secondary to instrumentation were managed at the American University of Beirut Medical Center. Five had upper AT injuries that included three hypopharyngeal, one esophageal, and one gastric lesion. The remaining three patients had lower AT injuries involving the transverse colon in one and the rectum in two. All the patients but two (one with a hypopharyngeal and one with an esophageal injury) were managed surgically and all survived. These rare injuries are discussed in addition to the preventive measures to be taken.

ホジキン病・非ホジキンリンパ腫同時発症の一例

Discordant malignant lyphoma composed of Hodgkin's disease (HD) and non-Hodgkin lymphoma (NHD) which occurred in a 38 years-old Japanese male is reported. He suffered from slight fever (38°C), general fatigue since December 25 in 1985. Thereafter, axiller and inguinal lymph nodes swelling was noticed. Because of systemic lymph node swelling with anemia, he was hospitalized in Nagai City Hospital 2 weeks later. Cervical, axillar and inguinal lymph nodes were excised. He was received chemotherapy (Adr, End. Prd. L-Asp). 6 months after, he was transfered to Yamagata Prefectural Central Hospital. In spite of chemotherapy, he died of a clinically suspicious perforation of alimentary tract in January 1986. Autopsy was not permitted. Resected cervical and inguinal nodes revealed scattered mononucleated Hodgkin's (H) cells and multinucleated Reed-Sternberg (RS) cells with intermingled lymphocytes, eosinophils and plasma cells, so they were diagnosed as HD, mixed cellularity (MC) type. Axillar node showed a diffuse proliferation of small and large mononucleated cells with prominent nucleoli, without diagnostic H cells and/or RS cells, and diagnosed as NHL, diffuse, mixed. Immunohistochemically, some of H cells and RS cells in cervical and inguinal nodes were positive for B1, MB1 and polyclonal cIgs (IgG, A, κ/IgG, A κ, λ). On the other hand, tumor cells in axillar node showed monoclonal cIg (IgG, κ). In the nodes of HD, there were small number of medium sized cells, which had a nucleus with prominent nucleolus and dispersed chromatin and were positive for B cell markers (B1, MB1) and polyclonal cIgs (IgG, A, κ/IgG, κ λ). LeuM1 was not detected in H cells, RS cells and diffuse lymphoma cells. This case was suggestive that some sort of HD was of lymphocyte origin and has some possibilities to develop a simultaneous progression to diffuse lymphoma.