Ileal Perforation Research Articles

Typhoid ileal perforation: a 13-year experience

Typhoid fever is endemic in many developing countries with a high rate of complications. Aim of this study is to analyse epidemiological features, clinical presentations, complications and therapeutic outcomes of enteric perforation peritonitis diagnosed and treated in our hospital. Records of total number of 646 patients, who presented with perforation peritonitis due to enteric fever in the surgical emergency unit of Dr Ram Manohar Lohia hospital, New Delhi between January 2001 and December 2013, were reviewed retrospectively. Descriptive statistics was used to analyze the data. Out of 646 patients, 62 (9.59%) presented in shock. Stomal, peristomal, local and systemic complications were high in these patients. Primary closure was done in 212 (33.12) patients, primary ileostomy was created in 410 (64.06) patients, and resection and anastomosis was done in 24 (3.75) patients. Thirteen patients (2.01%) died of typhoid intestinal perforation. To prevent complications of typhoid fever, in addition to control sanitation, it is also important to control quackery and malpractices. Awareness and education about the disease, its nature and complications will also be of great help.

Spontaneous bile duct perforation with cystic fibrosis and meconium ileus

Abstract Spontaneous bile duct perforation in the newborn is rare, with less than 150 cases reported. A term male newborn presented with abdominal distention and respiratory distress on the first day of life. Paracentesis revealed 420 mL of bile without succus or meconium, and laparoscopic washout and drainage was performed. A follow-up contrast enema several days later revealed a microcolon. The second operation confirmed the spontaneous bile duct perforation, but also revealed meconium ileus with ileal perforation and thick meconium. A sweat chloride study was abnormal and the patient was homozygous for the delta-F508 mutation. This is the first reported case of spontaneous bile duct perforation in association with meconium ileus or cystic fibrosis.

Gut wall replacing type of gastrointestinal stromal tumor presenting as a perforation of the ileal diverticulum

Gastrointestinal stromal tumors (GISTs) usually form a well-circumscribed mass. Very rarely, however, sporadic GISTs show gut-wall replacing growth, similar to the diffuse hyperplasia of interstitial cells of Cajal (ICC) observed in patients with neurofibromatosis type 1 (NF1) and hereditary GIST. Here we describe a patient with ileal perforation caused by this unusual type of GIST. An 82-year-old man was admitted to the emergency department with sudden abdominal pain. Following a provisional diagnosis of perforation of Meckel's diverticulum, he underwent segmental resection of the small intestine. Macroscopic examination revealed a diverticulum-like structure 2.5cm in size near the site of mesenteric attachment of the ileum. Histological examination showed diffuse and nodular proliferation of spindle cells positive for c-KIT and CD34 that had replaced the muscularis propria of the small intestine. Mutational analyses of the lesions revealed monoclonality of proliferating cells with a somatic mutation in c-kit exon 11 (p.Leu576Pro). Gut-wall replacing type of GIST should be recognized as a specific type of GIST causing diverticulum-like structures of the gastrointestinal tract.

Pazopanib plus weekly paclitaxel versus weekly paclitaxel alone for platinum-resistant or platinum-refractory advanced ovarian cancer (MITO 11): a randomised, open-label, phase 2 trial

Inhibition of angiogenesis is a valuable treatment strategy for ovarian cancer. Pazopanib is an anti-angiogenic drug active in ovarian cancer. We assessed the effect of adding pazopanib to paclitaxel for patients with platinum-resistant or platinum-refractory advanced ovarian cancer. We did this open-label, randomised phase 2 trial at 11 hospitals in Italy. We included patients with platinum-resistant or platinum-refractory ovarian cancer previously treated with a maximum of two lines of chemotherapy, Eastern Cooperative Oncology Group performance status 0-1, and no residual peripheral neurotoxicity. Patients were randomly assigned (1:1) to receive weekly paclitaxel 80 mg/m(2) with or without pazopanib 800 mg daily, and stratified by centre, number of previous lines of chemotherapy, and platinum-free interval status. The primary endpoint was progression-free survival, assessed in the modified intention-to-treat population. This trial is registered with ClinicalTrials.gov, number NCT01644825. This report is the final analysis; the trial is completed. Between Dec 15, 2010, and Feb 8, 2013, we enrolled 74 patients: 37 were randomly assigned to receive paclitaxel and pazopanib and 37 were randomly assigned to receive paclitaxel only. One patient, in the paclitaxel only group, withdrew from the study and was excluded from analyses. Median follow-up was 16·1 months (IQR 12·5-20·8). Progression-free survival was significantly longer in the pazopanib plus paclitaxel group than in the paclitaxel only group (median 6·35 months [95% CI 5·36-11·02] vs 3·49 months [2·01-5·66]; hazard ratio 0·42 [95% CI 0·25-0·69]; p=0·0002). We recorded no unexpected toxic effects or deaths from toxic effects. Adverse events were more common in the pazopanib and paclitaxel group than in the paclitaxel only group. The most common grade 3-4 adverse events were neutropenia (11 [30%] in the pazopanib group vs one [3%] in the paclitaxel group), fatigue (four [11%] vs two [6%]), leucopenia (four [11%] vs one [3%]), hypertension (three [8%] vs none [0%]), raised aspartate aminotransferase or alanine aminotransferase (three [8%] vs none), and anaemia (two [5%] vs five [14%]). One patient in the pazopanib group had ileal perforation. Our findings suggest that a phase 3 study of the combination of weekly paclitaxel plus pazopanib for patients with platinum-resistant or platinum-refractory advanced ovarian cancer is warranted. National Cancer Institute of Napoli and GlaxoSmithKline.

Spontaneous Intestinal Perforation in Neonates

Background: The term Spontaneous Intestinal Perforation (SIP) suggests a perforation in the gastrointestinal tract of a newborn with no demonstrable cause.Methods: Four neonates presenting with spontaneous bowel perforation were analyzed with respect to clinical presentation, management and outcome.Results: The mean age at presentation was 11.4 days. There were three males and one female. One of the neonates was preterm, very low birth weight and the other three were full term. Two neonates underwent emergency exploratory laparotomy and two were initially managed by peritoneal drainage in view of poor general condition; one of them improved and did not require further operative intervention. The preterm very low birth weight neonate was stabilized and explored after 48 hours. Intra-operatively, two of them had two ileal perforations each which required ileostomy; one had single perforation in the transverse colon which was primarily repaired. All four had an uneventful recovery.Conclusion: SIP is a distinct clinical entity and has better outcome than neonates with intestinal perforation secondary to Necrotizing Enterocolitis (NEC).

Spontaneous intestinal perforation in neonates.

The term Spontaneous Intestinal Perforation (SIP) suggests a perforation in the gastrointestinal tract of a newborn with no demonstrable cause. Four neonates presenting with spontaneous bowel perforation were analyzed with respect to clinical presentation, management and outcome. The mean age at presentation was 11.4 days. There were three males and one female. One of the neonates was preterm, very low birth weight and the other three were full term. Two neonates underwent emergency exploratory laparotomy and two were initially managed by peritoneal drainage in view of poor general condition; one of them improved and did not require further operative intervention. The preterm very low birth weight neonate was stabilized and explored after 48 hours. Intra-operatively, two of them had two ileal perforations each which required ileostomy; one had single perforation in the transverse colon which was primarily repaired. All four had an uneventful recovery. SIP is a distinct clinical entity and has better outcome than neonates with intestinal perforation secondary to Necrotizing Enterocolitis (NEC).

English

PURPOSE: To determine the role of enteric fever in ileal perforations. METHODS: A prospective cohort of 44 patients of ileal perforation was subjected to clinical examination and investigations like blood, ulcer edge biopsy, stool from the site of perforation and polymerase chain reaction (PCR) were subjected to culture to determine the predominant aerobic bacterial. RESULTS: Mortality was 22.7%. Highest isolation rate was seen in PCR (34.1%) followed by ulcer edge (25%) culture. CONCLUSIONS: Enteric fever organisms are not the predominant causative agents of ileal

Surgical Audit of Patients with Ileal Perforations Requiring Ileostomy in a Tertiary Care Hospital in India.

Introduction. Ileal perforation peritonitis is a frequently encountered surgical emergency in the developing countries. The choice of a procedure for source control depends on the patient condition as well as the surgeon preference. Material and Methods. This was a prospective observational study including 41 patients presenting with perforation peritonitis due to ileal perforation and managed with ileostomy. Demographic profile and operative findings in terms of number of perforations, site, and size of perforation along with histopathological findings of all the cases were recorded. Results. The majority of patients were male. Pain abdomen and fever were the most common presenting complaints. Body mass index of the patients was in the range of 15.4–25.3 while comorbidities were present in 43% cases. Mean duration of preoperative resuscitation was 14.73 + 13.77 hours. Operative findings showed that 78% patients had a single perforation; most perforations were 0.6–1 cm in size and within 15 cm proximal to ileocecal junction. Mesenteric lymphadenopathy was seen in 29.2% patients. On histopathological examination, nonspecific perforations followed by typhoid and tubercular perforations respectively were the most common. Conclusion. Patients with ileal perforations are routinely seen in surgical emergencies and their demography, clinical profile, and intraoperative findings may guide the choice of procedure to be performed.

Spectrum of perforation peritonitis in Kashmir: a prospective study at our tertiary care centre

Background: Objective of this study was to study the spectrum of perforation peritonitis in Kashmir. Like all over world, perforation peritonitis is the most prevalent surgical emergency tackled & treated by a surgical team in Kashmir. The etiology leading to peritonitis in tropical countries shows a different spectrum from its western world. This study was conducted at Govt. Medical College & Associated hospitals, Srinagar, Jammu & Kashmir in department of general surgery with aim to highlight the spectrum of perforation peritonitis treated and to improve its outcome thereafter. Methods: A prospective designed study including 356 patients admitted and diagnosed as perforation peritonitis were studied in terms of clinical presentations, etiology, site of perforation, surgical treatment, post-operative complications and mortality, at GMC Srinagar over a period of two years from Feb 2011 to Jan 2013. All patients were resuscitated, underwent emergency exploratory laparotomy and on laparotomy cause of perforation peritonitis was found and controlled. Results: The most common cause of perforation in our series was perforated duodenal ulcer (189 cases) followed by perforated appendix (53 cases), ileal perforation (53 cases), gastric perforation (25 cases) and the rest being perforations of large gut, Meckel’s diverticulum, jejunal perforation, GB perforation. Traumatic gut perforations generally following blunt trauma seem to be on rise. The mortality rate in our series was 10.2% with a morbidity rate of nearly 28%, wound infection being the commonest. Conclusions: The etiology of perforation peritonitis in Kashmir continuously differs in spectrum from western country. Largest part of perforations were noticed in the upper part of the gastrointestinal tract contrary to the western countries where the perforations are mostly encountered in the distal part. The commonest cause of perforation peritonitis in our setup is perforated duodenal ulcer, followed by perforated appendix, ileal perforations. Majority of the large bowel perforations are secondary to obstruction with transmural necrosis. Perforations secondary to malignancy are not common in our part.

Spontaneous ileal perforation complicating low anorectal malformation.

Anorectal malformation is a common anomaly in neonates. Although colorectal perforations have been reported as a complication, ileal perforation is rarely encountered. This is a report of a 2-day-old boy presenting with a low anorectal malformation, complicated with ileal perforation, necessitating laparotomy and ileal repair. Anoplasty was done for the low anomaly. Early presentation and prompt treatment of anorectal malformations is important to prevent such potential life threatening complication.

Nonsteroidal anti-inflammatory drugs: An unusual cause of multiple ileal perforations

Introduction: In this case report, we describe a rare case of pneumoperitoneum with peritonitis due to multiple ileal perforations with a history of high doses of diclofenac sodium usage. case report: A young adult male with recent history of high doses of Nonsteroidal anti-inflammatory drugs (NsAIDs) presented in emergency department with acute onset pain in right iliac fossa with high grade fever and tachycardia for 12 hours. Abdomen was tender in the right iliac fossa with guarding. X-ray of chest showed free gas under the diaphragm. Exploratory laparotomy was done and showed multiple ileal perforations. ressection and anastomosis of the affected segment was done, both ends brought as double barrel ileostomy which was reversed later on without any complication. conclusion: High doses of Nonsteriodal anti-inflammatory drugs can cause multiple ileal erosions and perforation and should be considered in the the differential diagnosis, if other possibilities are excluded.

Ileal Perforation Caused by Typhoid Fever

Background: Typhoid fever is a systemic infectious disease specific to human beings which is caused by a gram-negative bacillus (Salmonella typhi). Its incidence demonstrates significant variations in different regions of the world. It is generally seen in children of the school age. In developing countries, its most widely seen, and serious complication is intestinal perforation (IP). IP is generally seen within the third week of the disease. In children, it can onset with necrotic ileal Peyer’s patches which progress to diffuse peritonitis if not treated with appropriate medical therapy or in cases of delayed diagnosis. In these conditions, it requires surgical treatment . Despite novel antibiotics, and improvements in surgical techniques, mortality rates still range between 9, and 22 percent. Conclusion: This case report aims to distract attention to the importance of appropriate, and timely surgical intervention in a 15-year-old boy who presented with terminal ileum perforation developed secondary to inappropriately treated typhoid fever.

Early Experience with Stapled Gastrointestinal Anastomoses in a Nigerian Hospital.

Background:Hand-sewn gastrointestinal anastomoses has been the traditional approach to gastrointestinal anastomosis in Nigeria while stapled anastomoses are infrequently performed in few centers.Objectives:To describe the outcome of our initial experience with stapled gastrointestinal anastomoses in a semi-urban patient population.Patients and Methods:Consecutive patients who had stapled gastrointestinal anastomoses between January 2011 and June 2014 in a Nigerian tertiary hospital were prospectively evaluated. Indications for operation, procedures performed and anastomoses constructed and postoperative outcome of each patient were documented.Results:Nineteen patients including seven males and 12 females had stapled anastomoses within the period. Their ages ranged between 41 and 68 (mean 52.5) years. Six (31.6%) Roux-en-Y gastrojejunostomies, 6 (31.6%) ileo-colic, 3 (15.8%) ileo-ileal, 2 (10.5%) colo-colic, and 2 (10.5%) colo-anal anastomoses were performed. Indications include antral gastric cancer in 4 (21.1%), right colon cancer 4 (21.1%), ileal perforations in 3 (15.8%) while 2 (10.5%) each had left colon cancer, common bile duct obstruction, rectal cancer and ruptured appendix. Mean duration of operation was 108 ± 46 min and mean duration of postoperative stay was 5 ± 2.6 days. No intraoperative complications were recorded and no anastomotic leakage occurred. At a median follow-up of 5 months no staple related stricture had occurred.Conclusions:Stapled gastrointestinal anastomoses are associated with a good outcome in our center. We propose a prospective, large-population randomized comparison of the technique with hand-sewn anastomoses.

Acute Physiological and Chronic Health Evaluation II Score and its Correlation with Three Surgical Strategies for Management of Ileal Perforations.

Introduction:Ileal perforation peritonitis is a common surgical emergency in the Indian subcontinent and in tropical countries. It is reported to constitute the fifth common cause of abdominal emergencies due to high incidence of enteric fever and tuberculosis in these management based on Acute Physiological and Chronic Health Evaluation II (APACHE II) score.Methods:The following study was conducted in the Department of General Surgery, Government Medical College, Patiala. A total of 57 patients were studied and divided in to Group I, II, and III. APACHE II score accessed and score between 10 and 19 were blindly randomized into three procedures primary closure, resection-anastomosis, and ileostomy. The outcome was compared.Results:Ileal perforations were most commonly observed in the third and fourth decade of life with male dominance. APACHE II score was accessed and out of total 57 patients, 6 patients had APACHE II score of 0–9, 48 patients had APACHE II score of 10–19, and 3 patients had APACHE II score of ≥20. In APACHE II score 10–19, 15 patients underwent primary closure, 16 patients underwent resection-anastomosis, and 17 patients underwent ileostomy.Discussion and Conclusion:Primary closure of perforation is advocated in patients with single, small perforation (<1 cm) with APACHE II score 10–19 irrespective of duration of perforation. Ileostomy is advocated in APACHE II score 10–19, where the terminal ileum is grossly inflamed with multiple perforations, large perforations (>1 cm), fecal peritonitis, matted bowel loops, intraoperative evidence of caseating lymph nodes, strictures, and an unhealthy gut due to edema.

Testicular Seminoma and Peritonitis about One Case at the Yalgado Ouedraogo University Hospital of Ouagadougou

Introduction: Testicular seminoma is a highly lymphophilic germ cell tumor. It is the most common germ cell tumor in young adults. We are reporting one case of testicular seminoma complicated with an acute generalized peritonitis (AGP), in order to describe the circumstances of diagnosis and discuss about treatment. Observation: It involved a 39-year-old patient, admitted for vague abdominal pains that were evolving since 72 hours with a history of right orchiectomy because of testicular seminoma in 2011. The analysis revealed a peritoneal syndrome, a right inguinal lymphadenopathy of 10 cm diameter and an empty right scrotum. The exploration revealed fistulized necrotic retro-peritoneal lymphadenopathies in the peritoneal cavity and ileal perforation on contact with these lymphadenopathies. Necrosectomy and ileal resections were performed. After the operation, the scanner revealed a conglomeration of retro-peritoneal adenomegalies extending to the right femoral region associated with bilateral pleurisy. The β-HCG and the LDH were 8000 IU/L and 24,500 IU/L, respectively. The seminoma was ranked T3N3M1. The immediate post-operative care was uneventful. The patient was lost from sight for a month and was readmitted in a context of alteration of his general condition. He died before the end of the pre-chemotherapeutic assessment. Conclusion: Scrotal mass is the usual way of revelation of testicular seminoma. In poorly followed-up cases, exceptional complications such as peritonitis may occur and are direct consequences of poor prognosis.

Free Perforation of Ileal Tubercular Ulcer- A Case Report and Literature Review

Primary intestinal tuberculosis is unusual in North American, European and Caribbean countries. Its diagnosis is often surprising and differentiation from inflammatory bowel diseases is difficult. Intestinal perforation is an uncommon but potentially fatal complication of intestinal tuberculosis. There is no reported case of ileal tubercular ulcer perforation from the Caribbean. We present a 59 year old HIV negative patient presented with peritonitis with solitary perforation of terminal ileum. Histology revealed presence of Langerhan’s cell with caseating granulomatous inflammation and culture grew acid fast bacilli. A subsequent Manteaux test was strongly positive. There was no radiological evidence of pulmonary tuberculosis. Patient was started on anti-tubercular therapy and it is now over one year, the symptoms have not recurs back again.

Backwash ileitisを合併し，術後に回腸穿孔を来した潰瘍性大腸炎の1例

Backwash ileitisを合併し，術後に回腸穿孔を来した潰瘍性大腸炎の1例

English

BACKGROUND: Management of non-traumatic perforation of the small intestine has always been a consideration for surgeons because of associated enormous morbidity and mortality. There is a paucity of data on the management of non-traumatic perforation of the small intestine. AIM: To study incidence, etiopathogenesis, clinical profile and treatment modalities. MATERIALS AND METHODS: A prospective study was conducted between October 2012 to October 2014, which involved analysis of 55 patients treated for non-traumatic perforation of small intestine. Clinical profile and management of the patients were studied. RESULTS: The most common non-traumatic perforation of small intestine was DU perforation (54.5%) followed by ileal(typhoid) perforation (32.7%), tuberculosis (5.45%) and followed by perforation due to ascaris(3.6%) and secondary to obstruction(1.81%). After exploratory laparotomy primary repair with omental patch was the most frequent procedure followed by resection-anastomosis. The overall mortality rate was 20%. CONCLUSION: Early diagnosis, prompt pre-operative resuscitation, appropriate antibiotics, timely

Typhoid outbreak in Songkhla, Thailand 2009-2011: clinical outcomes, susceptibility patterns, and reliability of serology tests.

ObjectiveTo determine the clinical manifestations and outcomes, the reliability of Salmonella enterica serotype Typhi (S ser. Typhi) IgM and IgG rapid tests, and the susceptibility patterns and the response to treatment during the 2009–2011 typhoid outbreak in Songkhla province in Thailand.MethodThe medical records of children aged <15 years with S ser. Typhi bacteremia were analysed. The efficacy of the typhoid IgM and IgG rapid tests and susceptibility of the S ser. Typhi to the current main antibiotics used for typhoid (amoxicillin, ampicillin, cefotaxime, ceftriaxone, co-trimoxazole, and ciprofloxacin), were evaluated.Results S ser. Typhi bacteremia was found in 368 patients, and all isolated strains were susceptible to all 6 antimicrobials tested. Most of the patients were treated with ciprofloxacin for 7–14 days. The median time (IQR) of fever before treatment and duration of fever after treatment were 5 (4, 7) days and 4 (3, 5) days, respectively. Complications of ascites, lower respiratory symptoms, anemia (Hct <30%), and ileal perforation were found in 7, 7, 22, and 1 patients, respectively. None of the patients had recurrent infection or died. The sensitivities of the typhoid IgM and IgG tests were 58.3% and 25.6% respectively, and specificities were 74.1% and 50.5%, respectively.ConclusionMost of the patients were diagnosed at an early stage and treated with a good outcome. All S ser. Typhi strains were susceptible to standard first line antibiotic typhoid treatment. The typhoid IgM and IgG rapid tests had low sensitivity and moderate specificity.

Giant cell arteritis: Relapsing disease is a nightmare in diabetics

cyclophosphamide pulses. He developed solitary ileal perforation requiring surgery with ileostomy on follow up. Despite being on monthly CYC pulses for four months, along with steroids, he developed new vasculitic skin lesions along with new onset upper and lower limb peripheral neuropathy. He was given methylprednisolone pulses for three days along with hiking up of cyclophosphamide to biweekly with a plan to increase the interval to three weeks. He did not tolerate first session of plasmapheresis. Thecasehighlights the therapeutic challengeand lackof consensus guidelines in management of such cases of relapsing PAN.