Caecal Perforation Research Articles

Neurohypophyseal response to fluid resuscitation with hypertonic saline during septic shock in rats

Septic shock is a serious condition with a consequent drop in blood pressure and inadequate tissue perfusion. Small-volume resuscitation with hypertonic saline (HS) has been proposed to restore physiological haemodynamics during haemorrhagic and endotoxic shock. In the present study, we sought to determine the effects produced by an HS infusion in rats subjected to caecal ligation and perforation (CLP). Male Wistar rats were randomly grouped and submitted to either CLP or sham surgery. Either HS (7.5% NaCl, 4 ml kg(-1) i.v.) or isotonic saline (IS; 0.9% NaCl, 4 ml kg(-1) i.v.) was administered 6 h after CLP. Recordings of mean arterial pressure and heart rate were made during this protocol. Moreover, measurements of electrolyte, vasopressin and oxytocin secretion were analysed after either the HS or the IS treatment. Six hours after CLP, we observed a characteristic decrease in mean arterial pressure that occurs after CLP. The HS infusion in these rats produced a transient elevation of the plasma sodium concentration and osmolality and increased plasma vasopressin and oxytocin levels. Moreover, the HS infusion could restore the mean arterial pressure after CLP, which was completely blunted by the previous injection of the vasopressin but not the oxytocin antagonist. The present study demonstrated that rats subjected to CLP and an infusion of hypertonic saline respond with secretion of neurohypophyseal hormones and a transient increase in blood pressure mediated by the V(1) receptor.

English

Acute pseudo-obstruction of the colon(Ogilvie's syndrome) involves acute colonic distension without mechanical obstruction or stercoroma in a previously healthy colon. Colonic pseudo-obstruction can be diffuse or segmental. The cause for idiopathic colon dilatation is not known. Caecal rupture due to colonic ileus is rare and has a mortality rate of 43 per cent. We report a case of idiopathic caecal dilatation causing caecal perforation. On emergency laparotomy, caecal perforation secondary to segmental caecal dilatation without organic obstruction was found in this patient.

Primary tuberculous appendicitis presented with caecal perforation: A case report

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

Serum Lysozyme (Muramidase) Levels in Intra-Abdominal Abscesses: An Experimental Study.

The role of serum lysozyme in the presence of intra-abdominal sepsis was studied to act as an adjunct to various other modalities used for diagnosing intra-abdominal abscesses. Lysozyme (muramidase) is a bacteriolytic enzyme located within phagocytic cells including leukocytes. We measured serum concentrations of lysozyme by a standard turbidimetric method on three groups of murine models. One group underwent caecal ligation and puncture (CLP), the second group underwent a sham operation, and the third group was used as controls. In mice with intra-abdominal abscesses secondary to caecal ligation and perforation (n = 30), the serum lysozyme levels were increased compared to the sham-operated mice (n = 30) and controls (n = 30) (p = <0.001). In this study, serum lysozyme levels have a high sensitivity and specificity related to the presence of an intra-abdominal abscess in mice. Clinical studies are required to demonstrate its role in humans.

Post Caesarean Caecal Perforation with Fecal Peritonitis

NJOG 2011 Nov-Dec; 6 (2): 58-59 DOI: http://dx.doi.org/10.3126/njog.v6i2.6762

A rare case of perforated caecum after acute pancreatitis

Isolated caecal perforation following pancreatitis is a rare event. We report a case of severe non-necrotising pancreatitis complicated by caecal perforation that was managed successfully.

BRCA1 gene therapy reduces systemic inflammatory response and multiple organ failure and improves survival in experimental sepsis

Sepsis-related complications and mortality remain a major clinical problem. Increased cell death and unresolved cellular repair have been implicated as key upstream mediators of sepsis-induced organ dysfunction and death. We hypothesised that gene therapy with BRCA1, a critical regulator of DNA damage repair and cell survival, would attenuate the sequelae of sepsis and peritonitis in mice subjected to caecal ligation and perforation (CLP) and thioglycollate stimulation. C57Bl/6J mice underwent sham or CLP surgery 3 days following treatment with either human BRCA1 adenovirus (AdBRCA1) or the adeno-CMV-null vector (Adnull). The 24-h post-CLP mortality was 2.8% vs 17.9% (P<0.001) and the median post-CLP survival was 50.5 vs 33 h (P<0.05) for AdBRCA1- vs Adnull-treated mice, respectively. AdBRCA1 therapy blunted CLP-associated cardiac, pulmonary, hepatic and renal dysfunction and also reduced CLP-elicited double strand breaks and apoptosis in the liver. BRCA1 gene therapy was associated with lower CLP-evoked cardiac and hepatic superoxide generation that in the liver was in part due to improved reactive oxygen species removal. CLP also elevated mesenteric arteriolar and serum intercellular adhesion molecule-1, both of which were partially abrogated with AdBRCA1 administration. Thioglycollate-challenged AdBRCA1-treated mice displayed reduced peritoneal neutrophil recruitment and dampened cytokine elaboration relative to their Adnull-treated counterparts. Taken together, we report a novel role of BRCA1 gene therapy in limiting systemic inflammation, multiple-organ failure and mortality in experimental sepsis.

Postvaginal Delivery Caecal Volvulus and Perforation

Intestinal obstruction is an uncommon complication of pregnancy and pueperium. It has different etiologies and voluvlus is one of the common causes. High index of suspicion is needed to diagnose it as initial presentation is nonspecific and that is critical to avoid adverse outcomes. We presented here one of these cases that followed vaginal delivery and ended with caecal perforation and hemicolectomy.

Six-year retrospective analysis of colonic perforation in neonates and infants: Single centre experience

Developing countries at tertiary referral centre. This study analysed the aetiology of colonic perforation (CP) in neonates and infants. Retrospective analyses of 60 CP cases (presented from May 2005 to May 2011) were done. The mean age at presentation was 8.33 ± 0.11 days (range, 2-110 days). The aetiology were Hirschsprung's disease (HD), necrotising enterocolitis (NEC) and idiopathic perforation in 78.33% (47/60), 6.67% (4/60) and 15% (9/60), respectively. There were 210 patients with histopathologically proven HD; 22.38% (47/210) cases of HD had CP. Most common site of perforation was mid-transverse colon (74%, 35/47) in HD patients. All HD-associated mid-transverse colonic, caecal, appendicular and ascending colon perforations (except one caecal perforation) had aganglionic recto-sigmoid region and ganglionic perforation site. Features of enterocolitis were not found in any HD patients. Two patients (3.33%) died due to sepsis. There was a high rate of primary HD-associated colonic perforation in this study. Colonic perforation may the initial presenting condition in HD disease. We advocate colonic biopsy to rule out HD in any neonate presenting with primary colonic perforation.

Resolution of critical haemodynamic instability with urgent decompressive mini-laparotomy for abdominal compartment syndrome - a case report

Abdominal compartment syndrome, a relatively recently identified disorder [1,2], is traditionally managed in theatre with a semi-elective surgical decompressive laparotomy leaving the abdomen open [3]. Fewer options exist, however, in patients who develop critical haemodynamic instability in the ICU. We describe the case of a 58-year-old woman admitted to the ICU with hypotension and abdominal distension. She had been discharged from the ICU 48 hours earlier after a prolonged admission with complications of a caecal perforation including ischaemic small bowel, fungal bloodstream infection and renal failure. On readmission to the ICU her abdomen was significantly distended without bowel sounds. Her haemoglobin was 88 g/l and lactate was 4.1 mmol/l. The patient was intubated, commenced on low-dose noradrenaline and taken for an abdominal computed tomography scan with oral contrast, which showed a large intraperitoneal fluid collection (Figure ​(Figure11). Figure 1 Abdominal computed tomography scan demonstrating intraperitoneal free fluid. Arrow indicates site of mini-laparotomy. A pigtail catheter was inserted into her left flank, but <100 ml clear fluid could be drained. Critical haemodynamic instability soon developed, with her mean arterial blood pressure falling to 35 mmHg, despite escalating the noradrenaline infusion to 70 μg/minute, repeated adrenaline boluses of between 100 and 500 μg (2 g total), and additional fluid resuscitation via the central access. Given the dire situation, after urgent consultation and instruction from the surgeon (who was not in the hospital) by telephone, an immediate bedside mini-laparotomy was performed to decompress her abdomen. This was performed by the ICU registrar who had no formal surgical training. A left-sided 7-cm lateral scalpel incision was made parallel to the midline laparotomy, through the abdominal layers of skin, scarpa's fascia, muscle and peritoneum. Care was taken not to damage with abdominal viscera by making the incision away from the patient's stoma site and digital insertion through the peritoneal layer. After the peritoneum was opened, vigorous abdominal compressions were performed evacuating approximately 3 l of straw-coloured fluid. The patient's abdomen became less tense, her circulation improved and she was weaned off noradrenaline over the next 20 minutes. The incision was covered with a stoma bag (Figure ​(Figure2)2) and a further 1.75 l were drained. Figure 2 Site of mini-laparotomy over the left flank. We describe a patient with abdominal compartment syndrome, secondary to tense ascites, which was a key factor resulting in the development of critical haemodynamic instability. An urgent decompressive mini-laparotomy resulted in resolution of the patient's haemodynamic instability. We wish to highlight that abdominal compartment syndrome is a reversible factor that can be corrected to prevent cardiac arrest.

Gastrointestinal basidiobolomycosis: an emerging fungal infection causing bowel perforation in a child

Basidiobolomycosis is an unusual fungal skin infection that rarely involves the gastrointestinal (GI) tract. We report a 10-year-old boy diagnosed as suffering GI basidiobolomycosis after being misdiagnosed first as suffering intestinal malignancy then schistosomiasis. The patient presented with fever, abdominal pain, vomiting, abdominal tenderness and rigidity with marked blood eosinophilia. Abdominal ultrasonographic and computed tomographic scans revealed a large caecal mass. Biopsy of the mass showed transmural granulomatous inflammation interpreted as schistosomal granuloma, ruling out lymphoma. The patient's condition deteriorated despite anti-schistosomal therapy. Emergency surgery was then performed, and caecal perforation was found. The mass was excised; cultures were negative and histopathological examination was suggestive of schistosomal granuloma. The mass recurred 3 weeks post-operatively. Second-opinion histopathological examination diagnosed Basidiobolus ranarum infection. Treatment with itraconazole produced marked improvement, with diminution of the mass. B. ranarum was unequivocally identified in the archival formalin-fixed and paraffin-embedded (FFPE) tissue by PCR. This case emphasizes the need to consider GI basidiobolomycosis in children presenting with fever, abdominal mass and eosinophilia, especially those complicated by bowel perforation.

Caecal perforation following a caesarean section

Caecal perforation following a caesarean section

Self-expanding metallic stents as bridge to surgery in obstructing colorectal cancer

A self-expanding metallic stent (SEMS) may relieve intestinal obstruction to permit elective resection of colorectal cancer presenting as an emergency. There have been concerns regarding the oncological consequences of this strategy. This study evaluated outcomes in patients with potentially curable colorectal cancer treated with a SEMS as a bridge to surgery. This retrospective study included patients with obstructing colorectal cancer in whom a SEMS procedure was attempted between January 2004 and August 2007. Palliative SEMS procedures were excluded. Outcomes for SEMS insertion and subsequent surgery were recorded with a focus on survival. SEMS insertion was attempted and achieved in 34 patients, of whom 30 were discharged after successful relief of obstruction. However, five patients needed acute surgery within 18 days owing to insufficient relief of obstruction (1), or tumour (3) or caecal (1) perforation, with one postoperative death. The remainder underwent elective surgery with no postoperative mortality. In all, 28 of 34 patients were stoma free after operation. The 3-year survival rate of all 34 patients was 74 (95 per cent confidence interval 53 to 86) per cent after a median follow-up of 33·7 months. A curative outcome was achieved in 30 patients. Although associated with significant short-term problems, a SEMS can be useful in converting an emergency into an elective situation. No adverse oncological consequences were identified.

Synchronous Ruptured Amoebic Liver Abscess With Caecal Perforation - A Rare Case Presentation

Amoebiasis refers to an infection caused by Entamoeba histolytica, a gastrointestinal infection that may or may not be symptomatic and can remain latent for years. Most infected people, perhaps 90%, are asymptomatic, but this disease can be fatal, too. Severe amoeba infection is known as invasive or fulminant amoebiasis. In invasive amoebiasis, the trophozoites penetrate the intestinal mucosa causing amoebic colitis. In about 10% of the cases, they can enter the blood stream and cause extra-intestinal amoebiasis. The invasive form is an unusual pathology and leads to life-threatening complications with high morbidity and mortality. Synchronous pathological lesions in liver and colon are rare. Still rarer is the occurrence of complicated colonic and hepatic invasive amoebiasis presenting as an acute abdomen. One such presentation of synchronous ruptured liver abscess with caecal perforation in a 64-year-old male is reported.

Syndrome d’Ogilvie après une césarienne : à propos d’un cas

Ogilvie's syndrome is a rare postsurgical complication. The high mortality rate (normally 15 to 31% and up to 45% after caecal perforation) explains the seriousness of this clinical situation. The early diagnosis is made by plain abdominal X-ray. Conservative treatment is usually effective and surgery should be reserved for complicated cases or refractory to conservative treatment. We report a case of Ogilvie's syndrome after cesarean section, which has been treated by conservative methods.

Colocutaneous fistula secondary to amoebiasis

Here we present an interesting and extremely rare case of a 66 year old male who developed a colocutaneous fistula secondary to amoebiasis. The patient presented with an acute history of right lower abdominal pain, weight loss and a palpable mass. A CT scan demonstrated a fluid filled cavity in the right iliac fossa consistent with an appendiceal abscess which was drained under radiological guidance. However, following drainage his symptoms remained requiring open surgical drainage, and a controlled caecostomy was performed due to a small caecal perforation. Despite appropriate conservative therapy he failed to progress, and developed localised sepsis in the right iliac fossa with a colocutaneous fistula, requiring a formal right hemicolectomy. The histological examination confirmed the presence of abundant trophozoites of Entamoeba histolytica.We highlight the fact that in the modern age of immigration and long distance travel, it will become increasingly likely that the so-called ‘tropical’ diseases will present throughout the world. This case also highlights the need to keep an open mind in cases that do not progress as expected, and to react accordingly to any unusual developments.

Postpartum caecal perforation due to endometriosis

The prevalence of endometriosis in women in the general population is in the region of 10% and it most commonly occurs in the pouch of Douglas, pelvic peritoneum and ovaries. However, extra-genital sites such as the small and large intestine can be involved. Extra-uterine endometrial tissue behaves just as uterine endometrial tissue and, therefore, undergoes hormone-induced changes during the menstrual cycle including bleeding. The clinical consequence of this is severe pain, which is the commonest presentation of endometriosis.1 During pregnancy the endometrial stroma undergoes decidualisation due to hormonal changes and the normally small cells of the endometrial stroma undergo enlargement. Ectopic endometrial tissue also undergoes decidualisation.2,3

Letters to the Editor

Letters to the Editor

Colon perforation secondary to porphyria

Acute intermittent porphyria (AIP) is a rare, inherited metabolic disorder of the haem biosynthesis pathway. The diagnosis is well known to cause significant diagnostic challenge due to its broad range of symptoms that may mimic many other conditions. We report a case of AIP that presented with caecal perforation, a clinical scenario that has not previously been reported in the literature.

Abdominal Wall Abscess Due to Penetrating Caecal Cancer: An Unusual Presentation

The common presentations of caecal cancer are anaemia, weight loss and obstructive symptoms. Caecal cancer perforation and abscess formation are rare and mostly intra- or retroperitoneal. We present a case of abdominal wall abscess secondary to penetrating caecal cancer, the inability of computed tomography scan in aiding the diagnosis and successful surgical excision. When caecal cancer presents atypically, the preoperative diagnosis is difficult, but complete excision is possible even with abdominal wall penetration.