Case Of Perforation Research Articles

A Clinical Case of Stomach Perforation Concealed by a Foreign Body

Introduction. Stomach perforations caused by ingested foreign bodies are extremely rare injuries in adults, accounting for less than 1% of all gastrointestinal perforations. The clinical picture is diverse and often presents a diagnostic problem. There are few publications reporting such cases in literature.Materials and methods. Using the example of a clinical case, this paper describes the clinical picture, diagnostic role of X-ray instruments and surgical tactics of diagnosing and treating a stomach perforation concealed by a foreign object, which occurred one week prior to admission. The patient V., 52 yo, was admitted to hospital on an emergency basis in the condition of moderate severity, complaining of abdominal pain for two days. The onset of the disease had no apparent reason. Similar pains had bothered the patient a week earlier the incident but were relieved without treatment.Results and discussion. On the basis of clinical and laboratory-instrumental data, acute pancreatitis was pre-diagnosed. Conservative drug therapy with positive dynamics was started. Two days later, computed tomography of the abdominal organs with intravenous bolus contrast was performed. According to the CT data, a foreign body in the abdominal cavity was identified, which rested on the liver at the level of the gallbladder, perforating the wall of the pyloric department of the stomach. Localized inflammatory effusion in the abdominal fat was observed. The patient was operated and discharged in satisfactory condition.Conclusion. Stomach perforations caused by small-sized foreign bodies are characterized by non-specific clinical manifestations. The use of radiation diagnostic methods facilitates the timely diagnosis and therapy choice in patients with stomach perforations caused by small-sized foreign bodies.

Bowel mucosal necrosis and perforation following administration of calcium polystyrene sulfonate (Kalimate) in patients with hyperkalemia: Report of two cases

AbstractHyperkalemia is a common problem in patients with acute or chronic kidney disease. Cation exchange resins, such as calcium polystyrene sulfonate (Kalimate) or sodium polystyrene sulfonate (Kayexalate), are frequently administered orally or rectally to correct hyperkalemia. Kalimate/Kayexalate administration has been reported to induce gastrointestinal injury. We report two cases of colonic necrosis and bowel perforation following Kalimate adminstration. A review of past literature pertaining to Kalimate/Kayexalate‐associated complications was performed.

Esophageal perforation following pedicle screw placement for the treatment of upper thoracic spinal tuberculosis: a case report and review of the literature

BackgroundThe technique of posterior pedicle screw fixation has already been widely applied in the treatment of upper thoracic spinal tuberculosis. However, lesions of tuberculosis directly invade the vertebrae and surrounding soft tissues, which increases the risk of esophageal perforation induced by the posterior pedicle screw placement. Herein, we report the first case of esophageal perforation following pedicle screw placement in the upper thoracic spinal tuberculosis, and describe the underlying causes, as well as the treatment and prognosis.Case presentationA 48-year-old female patient with upper thoracic spinal tuberculosis presented sputum-like secretions from the wound after she was treated with one-stage operation through the posterolateral approach. Endoscopy was immediately conducted, which confirmed that the patient complicated with postoperative esophageal perforation caused by screws. CT scan showed that the right screw perforated the anterior cortex of the vertebrae and the esophagus at the T4 level. Fortunately, mediastinal infection was not observed. The T4 screw was removed, Vacuum Sealing Drainage (VSD) was performed, and jejunum catheterization was used for enteral nutrition. After continuous treatment with sensitive antibiotics for 2.5 months and 5 times of VSD aspiration, the infected wound recovered gradually. With 18-month follow-up, the esophagus healed well, without symptoms of dysphagia and stomach discomfort, and CT scan showed that T2–4 had complete osseous fusion without sequestrum.ConclusionTuberculosis increases the risk of postoperative esophageal perforation in a certain degree for patients with upper thoracic tuberculosis. The damages to esophagus during the operation should be prevented. The screws with the length no more than 30 mm should be selected. Moreover, close monitoring after operation should be conducted to help the early identification, diagnosis and treatment, which could help preventing the adverse effects induced by the delayed diagnosis and treatment of esophageal perforation.

Pedicled Falciform Ligament Flap repair in a Recurrent peptic ulcer perforation: case report and review of literature

Cellan Jones omentopexy technique is the mainstay of emergency surgical repair of perforated gastric/duodenal ulcers. Falciform ligament pedicle repair is a feasible alternative technique for peptic ulcer perforation repair when omentopexy is not possible, such as previous abdominal surgeries, partial gastrectomy, colectomy, severely malnourished individuals and absence of omentum as developmental anomaly. Other methods like jejunal patch repair, partial gastrectomy, Roux-en-Y duodenojejunostomy, tube duodenostomy and pyloric exclusion have also been used but they are associated with significant post-operative morbidity and failure rates and involve great deal of technicality. Recurrent peptic ulcers are those ulcers that reappear after healing. We report a case of recurrent peptic ulcer perforation treated by utilising pedicled falciform ligament flap to repair the perforation, with no postoperative and one-month follow-up complications. An omental flap was not available in this case because of dense adhesions and inflammation at the site of previous omentopexy.

Acute respiratory effect of transpyloric feeding for respiratory exacerbation in preterm infants.

Gastroesophageal reflux may exacerbate chronic lung disease in preterm infants. We evaluated the short-term effects of transpyloric feeding on respiratory status in preterm infants during mechanical ventilation. We retrospectively collected data from the hospital information management system. To evaluate the effect of transpyloric feeding on oxygenation, we compared changes in SpO2/FiO2 ratios before and after commencing transpyloric feeding by a piecewise linear regression model. We examined 33 infants (median gestational age, 25.4weeks; median birth weight, 656g) who underwent transpyloric feeding. All tubes were placed at the bedside without fluoroscopy. No cases of unsuccessful placement, gastroduodenal perforation, or tracheal misinsertion occurred. Transpyloric feeding began at a median age of 18 (interquartile range, 15-23) days. Mean SpO2/FiO2 (±SD) ratios were 391 (±49), 371 (±51), 365 (±56), and 366 (±53) 72-96h before, 0-24h before, 48-72h after, and 96-120h after starting transpyloric feeding, respectively. The rate of change per hour of SpO2/FiO2 ratios increased 48-120h after compared with 0-96h before transpyloric feeding (0.03 [95% confidence interval,-0.10 to 0.17] vs.-0.29 [-0.47 to-0.12]) (p=0.007). No apparent changes occurred in the mean airway pressure, amplitude pressure, or pCO2. Transpyloric feeding during mechanical ventilation can prevent the deterioration of oxygenation without major complications at the stage of respiratory exacerbation in preterm infants.

Laparoscopic adenomyomectomy combined with levonorgestrel-releasing intrauterine system in the treatment of adenomyosis: Feasibility and effectiveness.

To evaluate the clinical efficacy and safety of laparoscopic adenomyomectomy combined with intraoperative replacement of levonorgestrel-releasing intrauterine system (LNG-IUS) in the treatment of symptomatic adenomyosis. This is a case-series study in a university medical center. A total of 52 patients with symptomatic adenomyosis were treated by laparoscopic adenomyomectomy combined with intraoperative replacement of LNG-IUS from January 2015 to July 2018. Visual analog scale, menstrual flow and uterine volume were compared before and after the surgery (3, 12 and 24 months). Meanwhile, LNG-IUS-induced adverse reactions (e.g. irregular vaginal bleeding, amenorrhea, expulsion, and perforation) were also recorded. All operations were successfully completed via laparoscopy without conversion to laparotomy. No severe complications were noted during the surgical procedure or follow-up period. The mean postoperative visual analog scale and menstrual flow scores and the volume of the uterus were significantly decreased (all P < 0.001) at 3, 12, and 24 months postoperatively, compared with preoperative scores. The clinical effective rates among the patients with dysmenorrhea were 98%, 96% and 96% at 3, 12 and 24 months after the operation, respectively. And the clinical effectiveness rate of menorrhagia was 97.6%, 95.2% and 95.2% at 3, 12 and 24 months after treatment, respectively. Among all related adverse reactions, amenorrhea was the most common (n = 12, 23.1%). There was one case of LNG-IUS perforation (1.9%) and two cases of expulsion (3.8%). Laparoscopic adenomyomectomy combined with intraoperative replacement of LNG-IUS is a novel and effective conservative surgical procedure for symptomatic adenomyosis treatment.

Analysis of 234 cases of colorectal polyps treated by endoscopic mucosal resection.

BACKGROUNDColorectal polyps refer to all neoplasms that protrude into the intestinal cavity. Researchers believe that 50%-70% of colorectal cancers originate from adenomatous polyps.AIMTo investigate the endoscopic morphologic features, pathologic types, and clinical situation; evaluate the efficacy and safety of endoscopic mucosal resection (EMR); and guide clinicians in their daily practice.METHODSTwo hundred thirty-four patients who underwent EMR in our hospital from January 1, 2018 to December 31, 2019 were recruited. Data including sex, age, endoscopic morphology of the polyps, and pathological characteristics were analyzed among groups.RESULTSA total of 295 polyps were resected from the 234 subjects enrolled in the study, of which 4 (1.36%) were Yamada type I. There were 75 (25.42%) type II, 101 (34.24%) type III, and 115 (38.98%) type IV adenomas. Among them, 41 were non-adenomas, 110 were low-risk adenomas, 139 were high-risk adenomas, and 5 were carcinomas. The differences in distribution were not statistically significant, with P values greater than 0.05. The risk of cancer significantly increased for polyps ≥ 1 cm in diameter (c2 = 199.825, P = 0.00). Regarding the endoscopic morphological features, congestion, erosion, and lobulation were more common on the surface morphology of high-risk adenomas and cancerous polyps (c2 = 75.257, P = 0.00), and most of them were Yamada types III and IV. In all, 6 of the 295 polyps could not be removed completely, with a one-time resection rate of 97.97%. There were two cases of postoperative bleeding and no cases of perforation, with an overall complication rate of 0.09%. CONCLUSIONColorectal polyps ranging from non-adenomatous polyps, low-risk adenomas, and high-risk adenomas to adenocarcinomas each has their own endoscopic features, while EMR, as a mature intervention, has good safety and operability and should be promoted clinically, especially at the primary care level.

Strongyloides colitis is an often misdiagnosed lethal infection that resembles ulcerative colitis: first case of colon perforation in an adult.

Strongyloides colitis is an often misdiagnosed lethal infection that resembles ulcerative colitis: first case of colon perforation in an adult.

Gastrointestinal perforations and associated risk factors in children after liver transplantation.

In this study, possible risk factors of gastrointestinal perforations (GIP) that increase mortality after liver transplantation in children were investigated. One hundred and thirty-one pediatric patients who underwent 139 liver transplants between January 2016 and February 2020 were evaluated retrospectively based on preoperative and surgical data. Furthermore, cases with biliary atresia, which constitute 26.7% (35) of the patients, were compared within themselves and with other groups. It was found that the cases that developed perforations were younger, lower in weight, and had higher number of surgeries than those who did not, while the mortality and morbidity rates were higher in these patients. When cases with biliary atresia were analyzed within themselves, no significant difference was found between perforated biliary atresia and non-perforated cases in terms of age, weight, and previous surgery. When biliary atresia and other etiologies were compared, biliary atresia cases were found to be transplanted at a younger age, at a lower weight, and this group had a higher risk for perforation. Early laparotomy should be performed in order to reduce mortality in GIPs. Patients that are younger, underweight, previously operated, and using mesh must be closely monitored.

Tension pneumoperitoneum following upper endoscopy

Perforation of the digestive tract is a rare complication of endoscopy. Massive accumulation of air within the peritoneum resulting in the abdominal compartment syndrome is much less common with <20 cases reported. In this report we present a case of jejunal perforation during an upper gastrointestinal endoscopy that resulted in tension physiology with mesenteric ischemia, severe acidosis, renal failure, coagulopathy and massive gastrointestinal hemorrhage. The patient had a sudden onset of shock as soon as her abdomen was decompressed, indicating that she possibly developed a reperfusion injury. She did not respond to resuscitative efforts and ultimately died.

Frequency and Complications of Ileostomy.

IntroductionIleostomies are life-saving procedures used for temporary fecal diversion in complicated cases of ileal perforation. However, an ileostomy is associated with several complications. The goal of this study was to determine the frequency and complications of ileostomy in the Jinnah Postgraduate Medical Centre, Karachi, Pakistan.MethodologyWe conducted a longitudinal observational study from July 2019 to July 2020. All patients older than age 12 receiving an ileostomy were included. Patient examinations were conducted on the first postoperative day and were assessed for hemorrhage and necrosis. Examinations were conducted on the seventh postoperative day to assess stoma retraction, stenosis, prolapse, and high-output fistula. Patients were monitored via follow-up in the outpatient clinic every 15 days to record any complications for three months until the reversal was performed. All data were analyzed using IBM SPSS Statistics for Windows, Version 25.0. (Armonk, NY: IBM Corp.).ResultA total of 84 patients who received ileostomies were included in the study. Most patients were male (n=62; 73.8%), and 22 were female (26.19%). Of the 84 patients in our study, 34 (40.48%) had tuberculous intestine, 23 (27.38%) had typhoid ileal perforation, 23 (27.38%) were trauma patients, and four patients (4.7%) had gangrenous appendicular perforation. 23 patients (27.3%) were discharged with no complications, and 61 patients (72.69%) developed complications. The most common complication was skin excoriation (19.4%), followed by wound infection (13%), nonfunctioning stoma (11.9%), prolapse and stenosis (6%), retraction (4.7%), high-output fistula (3.5%), parastomal hernia and necrosis (2.3% each), and hemorrhage (1.1%).ConclusionIleostomy is a common and lifesaving surgical diverting procedure. It is still common in our clinic due to late presentation by patients who need the procedure. Complications are common but manageable. Therefore, it is essential to recognize these complications and manage them early to reduce the morbidity of the patients.

Checkpoint Inhibitor Colitis Masked by Multi-drug Effect

Abstract Casestudy: The utilization of checkpoint inhibitors such as programmed cell death protein 1 (PD-1/PD-L1) inhibitors (nivolumab) and cytotoxic T-lymphocyte antigen 4 inhibitors (ipilimumab) for treatment of certain malignancies has steadily gained popularity. Medication related colitis is uncommon, with a reported incidence of 1–9% depending on the checkpoint inhibitor used, and the histologic features have been characterized in recent literature. Because of the immunomodulating effect of these drugs, infectious colitis is in the differential diagnosis of enteritis. Multi-drug therapy in many of these patients further complicates identification of the culprit drug. We present the case of a 63-year-old male with metastatic renal cell carcinoma being treated with both nivolumab and ipilimumab who presented with acute on chronic non-bloody diarrhea. His clinical course was complicated by hypotension, acidosis and coagulopathy. The clinical differential for his colitis was cytomegalovirus infection versus a checkpoint inhibitor colitis. Colonoscopy revealed continuous circumferential loss of vascularity and diffuse erythema throughout the colon. Histology showed acute colitis with prominent apoptosis, cryptitis, crypt abscesses, and rare ringed mitotic figures, but without architectural distortion. Occasional smooth purple crystals consistent with pill material were present in the mucosa, but without significant tissue reaction. No pathogenic organisms were identified, and a cytomegalovirus immunostain was negative. These histologic findings in concert with the clinical history are consistent with checkpoint inhibitor colitis and multi-drug effect. A review of the patient’s chart showed cholestyramine was added to the patient’s regimen during hospitalization, which was consistent with the morphologic appearance of the crystals. Given the acute complications of checkpoint inhibitor induced enterocolitis and potential for increased morbidity (rare cases of bowel perforation and subsequent resection), accurate diagnosis is imperative. Management of checkpoint inhibitor associated colitis ranges from initiation of immunosuppression to checkpoint inhibitor cessation. When these findings are masked by multi-drug effect, accurate diagnosis can be difficult.

Misoprostol in Cervical Preparation Before Brachytherapy – Single Institutional 6 Years’ Experience

To evaluate the efficacy of oral misoprostol in facilitation of tandem application to the cervix during brachytherapy in patients with cervical cancer. From 2013-2019, 306 patients with cervical cancer were evaluated for cervical dilatation during brachytherapy. Patients treated with radical radiation therapy undergoing intracavitory or interstitial brachytherapy were analyzed. All patients received 200 mg of misoprostol on the day prior and on the day of the procedure before tandem application. The entire group was analyzed in terms of age, stage and size of Hegar dilators used for cervical dilatation. The complications of brachytherapy – bleeding and uterine perforations were also evaluated. Of all cases, 4% were Stage IB3, 6% were Stage IIA, 12% stage IIB, 10% stage IIIA, 29% stage IIIB, 24% stage III C, and 15 % stage IVA respectively. Mean (±SD) age (range) was 48 (25–68) years. Intracavitory brachytherapy was performed in 275 cases (90%) and Interstitial brachytherapy was performed in 31 cases (10%). Application was significantly easier in the entire group and the average size of initial Hegar dilators used for cervical dilatation was 12 Fr (4 mm) in 63.3% cases. Due the ease of insertion of uterine tandem after cervical ripening in 232(84%) patients the intracavitory applicator insertion was performed under mild sedation. There was only one case of severe cramping pain abdomen after consumption of misoprostol. In 9 cases (2.94%) cervical os was nonnegotiable despite the usage of Misoprostol,6 cases in interstitial brachytherapy and 3 in intracavitory brachytherapy. No case of heavy bleeding was noted and moderate bleeding was noted in 8.3% cases. There were 3 cases (0.98%) of uterine perforation identified on the planning CT scan. Misoprostol administration for cervical ripening before brachytherapy facilitates the procedure, increases patient tolerability and comfort, and may decrease complication rates like inadvertent uterine perforation or false tract formation. It is also cost effective as it reduced the number of cases requiring systemic or regional anesthesia.

A rare complication of ERCP: duodenal perforation due to biliary stent migration.

Background and study aims Perforation of the duodenal wall opposing the major papilla due to a migrated pancreatobiliary stent rarely has been described in the literature as a complication of endoscopic retrograde cholangiopancreatography (ERCP). Factors associated with perforation from migrated stents from ERCP are unknown. Patients and methods This was a retrospective, observational study. Patients were identified from January 1, 1994 to May 31, 2019 in a prospectively maintained ERCP database. Results Eleven cases of duodenal perforation from migrated pancreatobiliary stents placed at ERCP were identified during the study period. All cases involved biliary stents, placed for biliary stricture management. The perforating stent was plastic in 10 cases (91 %). This complication occurred in one in 2,293 ERCP procedures in which a pancreatobiliary stent was placed. Conclusion This complication is more common with biliary stents compared to pancreatic stents. This may be related to the angle of exit of biliary stents being more perpendicular to the opposing duodenal wall and the near exclusive use of external pigtail plastic stents in the pancreatic duct. All perforating plastic stents were ≥ 9 cm in length. Longer stents may provide leverage for perforation with a migration event.

An Unusual Iatrogenic Injury of Urinary Bladder Following Foley’s Catheterization

Urinary bladder perforation is most commonly observed after pelvic trauma. It can also be a result of iatrogenic injury during various surgical procedures. Very rarely, diseased bladder can spontaneously rupture. Traumatic bladder rupture is a serious event with mortality rate approaching 50%. Urinary bladder diverticulae are present of the bladder wall and are a consequence of bladder outflow obstruction, for example in prostatic enlargement. Foley’s catheterization is most commonly associated commonly with urethral trauma. We presented a emphasis is made unique case of perforation of urinary bladder diverticulum after Foley’s catheterization. To the best of our knowledge, such a case has never been reported before in the medical literature. An emphasis was made on the fact that, physicians should keep in mind the differential of perforated urinary bladder while attending a patient with abdominal pain because the signs and symptoms are very non specificurinary bladder while attending a patient with abdominal pain just because its signs and symptoms are very non-specific. In addition, missing a perforated urinary bladder is easy and can result in significant morbidity and mortality. Keywords: Bladder Diverticulum; Urinary Catheters; Perforation.

Safety and efficacy of aflibercept in FOLFIRI regime in treatment of metastatic colorectal cancer in real clinical practice: results of Russian prospective multicentre observational study SAFETRAP

Aim. The main objective of the prospective multicentre observational study is to describe adverse events occurred during treatment with aflibercept plus FOLFIRI therapy in real life practice. In despite of broad use of aflibercept in Federal oncological centers, this regimen is still perceived by healthcare professionals (HCPs) as having worse safety profile in comparison with other antiangiogenic agents. Taking into account limited experience of using aflibercept in Russia it s critically important to evaluate and document adverse events occurred with treatment in aflibercept plus FOLFIRI regimen in patients with metastatic colorectal cancer (mCRC) in real-life practice. Methods. The physician selection was performed as a random process. Twenty sites with experience in treatment of mCRC patients were selected. The investigators were encouraged to enroll all patients meeting eligibility criteria in consecutive manner. Total number of included patients into the study patient was 101. Data were evaluable for 91 patients. 14 of 91 (15.4 %) patients didn ’t meet inclusion criteria and were excluded from the per protocol analysis: 10 patients didn ’t receive oxaliplatin within the last line of therapy preceding inclusion into the study and in 4 patients progression occurred more than 6 months after the end of adjuvant therapy. Results. Overall, 265 treatment emergent adverse events (TEAEs) occurred in the 77 patients analysed per protocol. In total, 23 grade 3 and 5 grade 4 TEAEs were reported by 16 and 4 patients, respectively. The most common TEAEs were nausea (68 events in 31 [40.3 %j patients), diarrhea (43 events in 25 [32.5 %j patients), hypertension (36 in 20 [26.0 %] patients), neutropenia (29 events in J5 [J9.5 %] patients), asthenia (28 events in 12 [15.6 %]patients). Three cases of grade 1-2 stomatitis were reported in 2 (2.6 %) patients. And one patient reported grade 1 epistaxis during the study. There was no case of gastrointestinal perforation, fistula development, ulceration, arterial or venous thromboembolism. During this study seven serious adverse events were documented in 5 (6.5 %) patients of 77. The reason for treatment discontinuation in 5 (11.1 %) of 45 cases was adverse event. No death, classified as related to any component of therapy, was reported in this study. Conclusion. This national (Russian) prospective multicentre non-interventional study conducted in patients with mCRC in daily practice suggests that aflibercept plus FOLFIRI has a manageable safety profile in line with VELOUR phase III study.

魚骨による消化管穿孔・穿通に対して保存的に対応した3例：初期治療後の長期経過について

魚骨による消化管穿孔・穿通に対して保存的に対応した3例：初期治療後の長期経過について

Laparoscopic Appendectomy: A Safe and Definitive Solution for Suspected Appendicitis

Introduction: Since conservative antibiotic treatment in uncomplicated appendicitis might not solve the clinical problem definitively, it has to compete with the results of today’s laparoscopic appendectomy. Methods: In a county hospital, accommodating also a pediatric department, all cases of appendectomy for suspected appendicitis over 15 years were analyzed retrospectively for the following items: beginning of symptoms, time from admission to surgery, surgical technique as “open,” “laparoscopic” or “converted,” if perforated at operation and histological confirmation of acute inflammation. Surgical morbidity was detected in distinct categories. To evaluate changes over time, 3 time periods of 5 years each were defined. Results: Resulting in a total of 1,956 cases there were 731 in group I, 633 in group II and 592 in group III within the 3 time periods, respectively. The median age was 17 years. The percentage of perforations was 16.8%. Those patients had – with 47 compared to 27 h – a significantly prolonged time from the beginning of symptoms to admission (p = 0.0001). The proportion of laparoscopic surgery rose from 83.3 (group I) to 98.3% (group III; p = 0.0001). The median postoperative hospital stay diminished from 4 to 3 days in nonperforated (p = 0.0001) and from 8 to 7 days in perforated cases (p = 0.0009). Surgical morbidity was reduced from 4.1% in the first to 1.7% in the third observation period (p = 0.0144). There were no surgical site infections during the last 5 years. Conclusions: Timely laparoscopic appendectomy in case of suspected appendicitis can be offered with an extraordinary low morbidity. Taking into account the complete solution of the otherwise pending threat, compared to conservative antibiotic treatment, it is safe and definitive.

Laparotomy for duodenal obstruction, caused by a renal haematoma after extracorporeal shockwave lithotripsy

Extracorporeal shockwave lithotripsy is a widely used, acceptable and common first line treatment for non-conservatively managed renal and ureteric stone disease. Although considered a relatively safe non invasive treatment for renal and ureteric stones, can carry with it significant associated morbiditiy especially in high risk patients, such as those who are anticoagulated. Renal haematomas are not an uncommon finding after extracorporeal shockwave lithotripsy, however, fewer than 1% of patients presenting with a symptomatic renal haematoma require intervention in the form of urgent embolisation under interventional radiology, or emergency nephrectomy. Rare cases of splenic and hepatic haematomas have been reported and rarer still cases of gastro-intestinal perforation following extracorporeal shockwave lithotripsy. We report a case with a significant renal haematoma needing emergency embolisation of the renal artery, and subsequent development of duodenal obstruction from direct haematoma compression requiring a laparotomy and intended duodenal jejunal bypass. Level of evidence: 5

Spontaneous Perforation of Pyometra: A Case Series and Review of the Literature

Background: Pyometra is an unusual condition commonly occurring in elderly postmenopausal females. Spontaneous perforation of pyometra is rare and challenging situation to diagnose for clinicians. A high index of suspicion is needed to make an appropriate diagnosis, as the presentation is generally vague and most patients are treated for acute abdomen, considering it as a surgical emergency. This article reports on 3 cases of spontaneous perforation of pyometra at the Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India.. Cases: Retrospective analysis of the medical records of 3 cases of pyometra perforation are presented. These cases of spontaneous perforation of pyometra are described in this article. Results: All 3 patients underwent exploratory laparotomy followed by hysterectomy, bilateral salpingo-oophorectomy, and peritoneal lavage. Postoperative extensive care in intensive care unit (ICU) and broad spectrum antibiotics helped the patients' recovery. Conclusions: Spontaneous perforation of pyometra should be considered as a differential diagnosis when a postmenopausal woman presents with an acute abdomen. Timely detection and early intervention can prevent associated morbidity and mortality that can occur with perforated pyometra.