Signs Of Acute Peritonitis Research Articles

P-BN05 Solitary jejunal diverticulum: a rare unexpected cause of chronic pneumoperitoneum

Abstract Background Jejunal diverticula are rare acquired herniation of the mucosa and submucosa through the muscularis propria. They are asymptomatic in the majority of cases, however, they can present with non-specific abdominal symptoms and rarely complicate leading to acute abdomen. Perforation usually results in symptoms and signs of acute peritonitis and it is not an identifiable aetiology of chronic pneumoperitoneum. Computed tomography scan may identify intestinal wall oedema, air bubbles travelling through the mesentery, free intra-abdominal air and/or fluid . Radiological diagnosis requires high index of suspicion of such pathology. We report a case of an isolated jejunal diverticulum as a cause for aseptic chronic pneumoperitoneum . Methods A 77-year-old female was referred to the ambulatory emergency surgical unit (AESU) with a 4-month history of nonspecific abdominal pain, considerable weight loss, diarrhea, nausea and a few episodes of vomiting.Physical examination revealed no constitutional signs of sepsis and her abdomen was mildly distended but soft and nontender to palpation. Laboratory investigations were unremarkable. CT scan of her abdomen and pelvis on her first visit showed pneumoperitoneum with associated low volume ascites, which raised the possibility of sealed gastrointestinal perforation. In the absence of any clear signs of sepsis, a strategy of ambulatory, conservative management and follow up was chosen. Four months after her initial presentation our patient presented with ongoing vague abdominal symptoms with weight loss and failure to thrive. A CT colonogram described pneumoperitoneum and larger volume of ascites is in comparison to the previous CT scan. There was an unusual pattern of mural gas in some loops of small bowel in the left side of the abdomen that suggested pneumatosis. MDT decided to proceed with diagnostic laparoscopy. Results Laparoscopy exploration revealed odorless pneumoperitoneum, moderate amount of non-turbid bile stained serous ascites and thin fibrinous covering. We identified a jejunal diverticulum associated with mesenteric air bubbles and moderately enlarged reactive feeling lymph nodes in the diverticular segment . A small bowel resection with a primary side-to-side anastomosis, washout of the abdomen and cholecystectomy were done through a Kocher’s subcostal incision. She made an uneventful post-operative recovery and was discharged home well on day 4. Histopathological examination of the resected specimens confirmed the presence of a ruptured isolated jejunal diverticulum with a breach in muscularis propria and chronic cholecystitis in the gallbladder. Conclusions In summary, our case report highlights the importance of being aware of the possibility of perforated jejunal diverticula as a possible source of chronic pneumoperitoneum causing chronic nonspecific abdominal pain, diarrhea and unexplained weight loss. The surgical option of segmental resection and primary anastomosis was beneficial in this patient. However, calculating the risk benefit ratio remains the mainstay of the management plan, which, as ever, should be tailored to each patient’s general condition and fitness with appropriate counselling and consent.

Personalized approach to acute peritonitis treatment based on genetic studies

The research presents treatment results of patients with peritonitis by using the personalized medicine principles, which are based on the choice of diagnostic, treatment and preventive measures taking in to account genetic, physiological, biochemical and other features of the patient.
 Purpose of the study. The treatment results improvement of patients with peritonitis, the reduction of the complications frequency.
 Materials and methods. 226 patients with signs of acute peritonitis had complex examination with serum cytokines and serotonin levels determination and analysis of the polymorphic sites alleles of IL1ß (-511C / T) and 5-HTTLPR genes by polymerase chain reaction evaluated the treatment outcomes using the developed algorithms. The treatment results with the use of developed algorithms were evaluated.
 Results. The processes of peroxide oxidation, antioxidant protection, proteolysis, fibrinolytic activity and their role in systemic disorders of homeostasis are shown. The connection between the nature of inflammatory reactions, its distribution in the peritoneal cavity and variants of the IL1ß gene (-511C/T) was proved. The relationship between the character of intestinal motility disorders in the postoperative period and variants of the 5-HTTLPR gene, which regulates the serotoninergic mechanisms of intestinal contractility, is shown. The algorithms for personalized approach to the peritonitis diagnostics, prognosis of and choice of treatment tactics were developed on the basis of the identified genetically determined individual characteristics of the inflammatory process. Advanced stages of surgical intervention were developed.
 Conclusion. Predictionofthecourseofperitonitis and the development of various complications based on genetic research allows developing algorithms of personalized therapeutic tactics, significantly improving the results of its treatment.

Laparoscopic Management: Spontaneous Chyloperitoneum in Pregnancy

<span lang=EN-GB style=font-size:11.0pt; mso-ansi-language:EN-GB>1. <span lang=EN-GB style=font-size:11.0pt; mso-ansi-language:EN-GB>Abstract <span lang=EN-GB style=font-size:10.0pt;mso-ansi-language: EN-GB>Chylous ascites, chyloperitoneum or chyloabdomen are all synonyms for the intra-abdominal collection of lymphatic fluid of different etiologies, with the characteristic finding of whitish, hazy, milk-like intraabdominal fluid. It is a rare event and, is frequently idiopathic, with diagnosis usually made at laparotomy, whenever signs of acute peritonitis are present. Peritoneal toilette and drainage are the only treatment required, and the prognosis is excellent. Chyloperitoneum in pregnancy is extremely rare, described in only a few reports in the literature [1-5] . Pregnancy used to be considered a relative contraindication for laparoscopic procedures; despite this, the use of laparoscopy for the treatment of acute disease in pregnant women has been progressively increased. We present a laparoscopic management and resolution of an acute peritonitis in a patient who was initially suspected of having a complicated acute appendicitis and was finally diagnosed with chyloperitoneum. The objective of this paper is to report a rare entity and insist on the possibility of laparoscopic management in these cases. <span lang=EN-GB style=font-size:11.0pt; mso-ansi-language:EN-GB>2. Keywords: Chylous Ascites; Chylous Peritonitis; Laparoscopic Surgery; Pregnancy

Prediction of Postoperative Complications in Acute Peritonitis

The ability to predict the possibility of postoperative complications is an important component of treatment of acute peritonitis. None of the known methods is fully accepted worldwide.The objective of the research was to develop an informative method for predicting postoperative complications.Materials and methods. A retrospective analysis of the results of treating 169 patients with peritonitis was made. 79 patients developed postoperative complications. 39 patients died. 123 patients were diagnosed with comorbidities. Clinical and laboratory data, parameters of the Mannheim peritonitis index, comorbidity class, and the patients’ age were analyzed using the variance analysis.Results and discussion. The prediction of postoperative complications may be carried out in two stages. Prior to surgery, preceding risk is estimated considering the nature of the underlying disease, clinical signs of acute peritonitis and comorbidity class. During surgery the final risk estimation is made taking into consideration the nature of the underlying disease, the Mannheim peritonitis index, comorbidity class, the number of band forms, use of the programmed peritoneal sanation. For each aforementioned indicator different number of points was determined. Patients were divided into several groups by the sum of these points: normal (2-4 points), increased (5.7 points), medium (8-9 points) and high (more than 10 points) risk of postoperative complications.Conclusions.The proposed prognostic scale allows us to identify groups of normal, increased, medium and high risk of postoperative complications in acute peritonitis.A two-phase prediction - before and during surgery – allow us to differentially apply preventive measures in the preoperative preparation, during surgery and in the postoperative period of treatment.

Challenging a classic myth: pneumoperitoneum associated with acute diverticulitis is not an indication for open or laparoscopic emergency surgery in hemodynamically stable patients. A 10-year experience with a nonoperative treatment

In patients presenting with acute diverticulitis (AD) and signs of acute peritonitis, the presence of extradigestive air (EDA) on a computer tomography (CT) scan is often considered to indicate the need for emergency surgery. Although the traditional management of "perforated" AD is open sigmoidectomy, more recently, laparoscopic drainage/lavage (usually followed by delayed elective sigmoidectomy) has been reported. The aim of this retrospective study is to evaluate the results of nonoperative management of emergency patients presenting with AD and EDA. The outcomes of 39 consecutive hemodynamically stable patients (23 men, mean age = 54.7 years) who were admitted with AD and EDA and were managed nonoperatively (antibiotic and supportive treatment) at a tertiary-care university hospital between January 2001 and June 2010 were retrospectively collected and analyzed. These included morbidity (Clavien-Dindo) and treatment failure (need for emergency surgery or death). A univariate analysis of clinical, radiological, and laboratory criteria with respect to treatment failure was performed. Results of delayed elective laparoscopic sigmoidectomy were also analyzed. There was no mortality. Thirty-six of the 39 patients (92.3%) did not need surgery (7 patients required CT-guided abscess drainage). Mean hospital stay was 8.1 days. Duration of symptoms, previous antibiotic administration, severe sepsis, PCR level, WBC concentration, and the presence of abdominal collection were associated with treatment failure, whereas "distant" location of EDA and free abdominal fluid were not. Five patients had recurrence of AD and were treated medically. Seventeen patients (47.2%) underwent elective laparoscopic sigmoidectomy for which mean operative time was 246 min (range = 100-450) and the conversion rate was 11.8%. Mortality was nil and the morbidity rate was 41.2%. Mean postoperative stay was 7.1 days (range = 4-23). Nonoperative management is a viable option in most emergency patients presenting with AD and EDA, even in the presence of symptoms of peritonitis or altered laboratory tests. Delayed laparoscopic sigmoidectomy may be useless in certain cases and its results poorer than expected.

EMPHYSEMATOUS HEPATIC ABSCESS ASSOCIATED WITH TRAUMA, NECROTIC HEPATIC NODULAR HYPERPLASIA AND ADENOMA IN A DOG: A CASE HISTORY REPORT

A 13‐year‐old male Setter‐Springer crossbred dog was presented with signs of acute peritonitis three days after blunt abdominal trauma. In abdominal radiographs, a bubbly accumulation of gas in the central and cranioventral parts of the liver silhouette and mild peritoneal effusion were seen. At laparatomy, firm, necrotic, nodular hepatic masses containing gas were found to be ruptured. The histologic diagnoses were hepatic adenoma with hepatic necrosis and nodular hepatic hyperplasia. The pathogenesis of hepatic abscessation and the radiographic differential diagnosis of extraluminal abdominal gas are discussed.

Asymptomatic Bilious Ascites Following Percutaneous Liver Biopsy

Asymptomatic bile leakage developed in a woman following percutaneous liver biopsy. The case is remarkable because features of cholestasis were not present at the time of biopsy, the bile leak occurred through the needle tract in the liver, billous ascites occurred without signs of acute peritonitis, and the complication was the initial manifestation of extrahepatic biliary obstruction due to encasement of the common bile duct by histiocytic lymphoma.