Perforation Of Small Intestine Research Articles

Effect of thoracic epidural block on infection-induced inflammatory response: A randomized controlled trial

PurposeEpidural block decreases inflammation and oxidative stress in experimental models of sepsis as well as after surgery. There is, however, no clinical evidence evaluating its effect on infection-induced inflammatory process. The present trial evaluated the effect of thoracic epidural block (TEB) on systemic inflammatory response in patients with small intestinal perforation peritonitis. Outcome measures included systemic levels of interleukin (IL)-6, IL-10, procalcitonin, and C-reactive protein and postoperative Sepsis-Related Organ Failure Assessment scores. Material and methodsSixty adult patients undergoing emergency abdominal laparotomy without any contraindication to TEB were randomized to receive general anesthesia alone or in combination with the TEB, which was continued for 48 hours postoperatively (n = 30 each). ResultsUse of TEB was associated with a statistically insignificant trend of preservation of anti-inflammatory response depicted by higher levels of IL-10 and lack of alteration in proinflammatory IL-6, along with appreciably lower procalcitonin levels, decreased incidence of raised C-reactive protein levels, and better postoperative SOFA score (P > .05). It resulted in significantly better postoperative respiratory function and faster return of bowel motility (P < .05). Although the sample size is too small for conclusive statement, none of the patients developed epidural abscess. ConclusionThoracic epidural block showed a trend toward better preservation of anti-inflammatory response and clinical recovery that, however, failed to achieve statistical significance (P > .05).

Value in palliative cancer surgery: A critical assessment.

Emergency operations are associated with increased morbidity, mortality, and cost compared to elective operations. Palliative and emergent surgery for patients with advanced malignancies is associated with additional risk and remains controversial. Emergent or palliative interventions can be broadly categorized according to indication. Tumor related complications (bleeding, obstruction, or perforation) merit specific consideration, as do specific presentations such as pneumoperitoneum, pneumatosis intestinalis, or peritonitis from other causes that may arise during active therapy for malignancies. Although nonoperative, endoscopic, and interventional treatment modalities are frequently available, surgery remains the only effective therapy in selected situations such as small intestinal obstruction and tumor perforation. Selection of patients for surgery requires consideration of factors including overall prognosis, performance status, and patients' priorities. Selection and risk assessment tools underscore the limited capacity of patients' with higher risk features for durable recovery but do not supplant nuanced clinical judgment. J. Surg. Oncol. 2016;114:311-315. © 2016 Wiley Periodicals, Inc.

Analysis of clinical characteristics of necrotizing enterocolitis in term infants

To investigate the characteristics and outcomes of necrotizing enterocolitis (NEC) in Chinese term infants population. A national neonatal necrotizing enterocolitis network was established. Neonates as having necrotizing enterocolitis with gestation age ≥37 weeks were identified if they met the accepted diagnostic criterion during the study period from Jan 1(st) 2011 to Dec 31(st) 2011. The data of maternal and neonates' characteristics, the comorbidities, the clinical interventions prior to NEC, the clinical courses and radiology results, the medical and surgical treatment and the outcomes were collected. SPSS 19.0 software was used to do statistic analysis. Logistic-regression models were used to analyze the risk factors for death in infants with NEC, odds ratio (OR) and 95% confidence interval (CI) were calculated. There were 231 067 newborn infants, 164 307 of them were term infants, admitted to 95 hospitals in main land China. There were 718 term infants were diagnosed as necrotizing enterocolitis with the incidence of 0.44%. There were 294 term infants cases identified as ≥stage 2 necrotizing enterocolitis for the analysis, including 193 cases of stage 2 and 101 cases of stage 3.The mean gestation age was (39.0±1.3) weeks, and the mean birth weight was(3 087.4±548.3)g. The percentage of small for gestation age was 20.4%. The onset age of NEC was 5 (2-11)d. The percentage of cases received breast milk feeding was 23.7%. The most common comorbidities were sepsis (9.5%, 28/294), asphyxia (9.5%, 28/294), pneumonia (7.8%, 23/294) and congenital megacolon (7.5%, 22/294). The bowel perforation rate was 13.9%. The rate of cases who received surgical treatment was 25.2%(76.6% small intestinal necrosis and 65.8% small intestinal perforation). The mortality rate was 28.9%(the mortality rate were 20.7% and 44.6% in stage 2 and stage 3 NEC, respectively). Noninvasive continuous positive airway pressure treatment for NEC (OR=5.278, 95% CI: 2.058-13.533, P<0.01) and NEC staging 3 (OR=3.156, 95% CI: 1.766-5.642, P<0.01) were statistically significantly associated with mortality of NEC. The term infants with necrotizing enterocolitis usually have the underlying comorbidities. The breastmilk feeding rate is low. Necrotizing enterocolitis remains high mortality in term neonates in Chinese neonatal units. Noninvasive continuous positive airway pressure treatment for NEC is statistically significantly associated with mortality of NEC.

Unexpected and unintentional fish bone ingestion causing acute abdomen and uncommon small intestinal perforation

Perforation of the mesenteric small bowel is an uncommon cause of acute abdomen in the emergency department. Early diagnosis is difficult owing to unspecific clinical presentations. The most common causes of perforation are tumor, trauma, Crohn's disease, ischemia, and foreign body ingestion. Currently, computed tomography (CT) is often the initial modality used to assess patients with acute abdomen, and the excellent anatomic details it provides, including segmental bowel wall thickening, mesenteric air bubbles, and fatty infiltration, may help the clinician to diagnose earlier and with greater ease. Here, we present a case of acute abdomen diagnosed as small bowel perforation due to unintentional fish bone ingestion using multidetector CT. The multiplanar reconstruction images from multidetector CT helped locate the perforation site before surgical intervention.

Toothpick perforation of small intestine in an adult

The patient presented in Emergency with Pain right iliac fossa for last 24 hours. It was sudden in onset, mild in intensity, non-radiating to any site, and was associated with mild fever. About 5-6 episodes of vomiting occurred in that period. Her menstrual history was normal. She was taking medication for Rheumatoid Arthritis fort last three months. With Alvarado Score of 6 a clinical diagnosis of Acute Appendicitis was made. X-ray Abdomen did not reveal any abnormality, Blood C/E, Urine C/E, Blood sugar blood urea and serum electrolytes. After preparation, patient was taken to the theatre. Rutherford Morrison incision was made. Her appendix was difficult to locate but was normal. Strangely a toothpick was seen in the mesentery of appendix and there was a pinpoint perforation in terminal ileum about two inches proximal to ileocaecal junction Fig 1. Margins were fresh and it did not give a look of old perforation. There were adhesions between loops of small intestine, which were also adherent to under surface of liver. After adhesionolysis, margins of perforation were trimmed and it was repaired in two layers (Inner vicryl 2/0 continuous and outer with prolene 4/0 interrupted. Appendicectomy was also performed. After washing abdominal cavity with 0.9 normal saline wound was closed in layers. Patient was given postoperative antibiotics and an analgesic, kept NPO for 24 hours, and was discharged successfully after 3 days. Later on patient was asked and she admitted taking a burger three days earlier but she did not remember any toothpick.

Role of Deliberate Creation of Control Enterocutaneous Fistula in Patients of Abdominal Tuberculosis with Perforation of Small Bowel and Matted Small Intestine

Objective: To study the results after forming the controlled enterocutaneous fistula in the patient of abdominal tuberculosis with matted and perforated small bowel. Design, place and duration of study This study based on therapeutic trial and conducted in one and half years from january1999 to june2001 at Mayo Hospital, Lahore. Patients and methods: All these 20 patients either operated in emergency or on elective list were malnourished, toxic and their operative findings were almost the same , these patients had extensively matted, friable and perforated gut. In these patients it was technically not possible to perform some definite procedure like right haemecolectomy or ileostomy with out increasing the morbidity or mortality. Under these circumstances, minimal surgical procedure which can be life saving is to oppose the anterior abdominal wall to the perforation and thus create a controlled enterocutaneous fistula. In 11 patients fistula closed on its own and in eight patients fistula remained patient and needed re-exploration and repair. Conclusion: This new method of treatment has yielded excellent results. We were able to cure the disease with no mortality. It is recommended that in cases of TB peritonitis with perforation and matted gut making of a controlled enterocutaneous fistula saves the life of the patient.

Sudden Death Due to Spontaneous Small Bowel Perforation within an Incarcerated Umbilical Hernia

Umbilical hernias are estimated to occur in up to 20% of patients with long-standing cirrhosis and ascites. Complications such as strangulation and infarction of the bowel or rupture of the bowel loops and/or hernia sac are uncommon but potentially life-threatening consequences. Often these events happen in association with abdominal trauma or after procedures such as paracentesis. Spontaneous rupture is more likely in cases where strangulation and subsequent necrosis of the bowel has weakened and thinned the incarcerated intestinal wall. We report a case of a 63-year-old male with a history of alcohol abuse complicated by cirrhosis and ascites who was found dead in his home approximately 30 minutes after last being seen alive. He was found at rest in a seated position without evidence of recent trauma. At autopsy, an ulcerated umbilical hernia was present containing a loop of perforated, necrotic small bowel. There was evidence of peritonitis including one liter of yellow-red fluid accumulation in the peritoneal cavity, multifocal areas of fibrinopurulent debris adherent to the small bowel, and a dull gray discoloration to the peritoneal lining. The case was signed out as death due to peritonitis and spontaneous perforation of small intestine due to strangulated and infarcted small intestinal umbilical hernia and the manner, natural. Although spontaneous perforation of the bowel within a hernia sac is uncommon, it may contribute to sudden death in patients lacking a history of trauma or recent medical procedures and physicians certifying these deaths should be aware of the possibility.

A Clinicopathological Study of Small Intestinal Perforations in Patients with Eosinophilic Granulomatosis with Polyangiitis

A Clinicopathological Study of Small Intestinal Perforations in Patients with Eosinophilic Granulomatosis with Polyangiitis

Computed Tomographic Demonstration of Ingested Press-Through Packages Causing Small Intestinal Perforation

Press-through packages (PTPs) are regularly used to enclose drugs, and are increasingly seen in cases of ingested foreign bodies in the alimentary tract. Most cases of ingested PTP-induced bowel perforation are difficult to diagnose. We herein present a case of preoperative computed tomography (CT) demonstration showing ingested PTP-induced small intestinal perforation. An index of high suspicion and early exact diagnosis by high-resolution CT are requisite to avoid deterioration of the patients’ condition and to improve outcome.

Primary T-Cell Lymphoma With Small Intestinal Perforation: A Case Report

Primary T-Cell Lymphoma With Small Intestinal Perforation: A Case Report

Bullet injury to great vessels of abdomen - a case report and review of literature

Bullet injury to the great vessels of abdomen is uncommon and has high mortality and morbidity including amputation. Many times there are other associated organ injuries. Though hypotension and absent or feeble peripheral pulse are good indicators of vascular injury, there can be normal blood pressure with palpable pulses initially when there are hematoma formation in a closed space and adequate fluid resuscitation. We report this uncommon presentation in a 26 years old gentleman who had bullet injury in the right lower flank of abdomen causing a longitudinal tear on the medial aspect of right external iliac vein (zone III injury) with multiple small intestinal perforations.

Multiple Small Intestine Perforations after Organophosphorous Poisoning: A Case Report

Organophosphate poisoning has significant gastrointestinal manifestations including vomiting, diarrhea, cramps and increased salivation. We report an uncommon gastrointestinal complication of multiple small intestinal perforations following organophosphorus poisoning. A 28-year old male presented after ingesting dichlorvos mixed with alcohol. Following the initial cholinergic symptoms, the patient developed severe shock with fever, attributed to aspiration pneumonia. Despite appropriate antibiotics, shock was persistent. Over the next 24-hours, he developed abdominal distension, loose stools and high nasogastric aspirates. Computed tomography showed pneumoperitonium. Exploratory laparotomy revealed six perforations in the jejunum and ileum. The involved portion of the bowel was resected and re-anastomosed, following which only 80-cm of small bowel was left. Postoperatively, shock resolved over 72-hours. However, over the next few days, patient developed features of anastomotic leak. Since only a small portion of the small bowel was preserved, a conservative approach was adopted. He deteriorated further and finally succumbed to the illness.

穿孔によって判明した小腸原発性diffuse large B cell lymphomaを合併したSjögren症候群の１例

穿孔によって判明した小腸原発性diffuse large B cell lymphomaを合併したSjögren症候群の１例

Examination of the Prognosis and Health-Related Quality of Life of Elderly Patients with Malignant Lymphoma

Introduction: As the population continues to advance in age, it is necessary to examine aggressive treatment for elderly patients with malignant lymphoma. However, chemotherapy can also reduce the health-related quality of life (QOL) in such patients. Therefore, we examined the impact of a change of treatment on elderly patients 80 years or older and their QOL.Methods: We enrolled 39 elderly malignant lymphoma patients, aged 80 years or older (median age, 85 years), who were treated in our department between September 2007 and September 2014. We administered a questionnaire survey to assess the QOL in 19 cases using SF36. We re-administered the survey to about 11 cases one year after the initial examination. As controls, we selected 78 patients with malignant lymphoma who were younger than 80 years.Results: The histological diagnosis was determined by lymph node biopsy in 34 cases, but in 5 cases, the diagnosis remained unknown because of the lack of superficial lymphadenopathy; in such cases the diagnosis was made using bone marrow, pleural effusion or ascitic fluid. Chemotherapy was administered to 34 patients. Eleven of 34 patients died; in ten patients the cause of death was recurrence or refractoriness to chemotherapy, and treatment-related death only occurred in one case. Eight patients exhibited partial response or greater after chemotherapy, but were lost to follow-up as they moved to a local care facility. With respect to the histological classification, there were 19 cases of diffuse large B-cell lymphoma (DLBCL), six cases of follicular, small lymphocytic, or mantle cell lymphoma, two cases of peripheral T-cell lymphoma, four cases of the high-grade group and three cases of Hodgkin's disease. We examined 18 cases of newly diagnosed DLBCL. Eleven cases were treated with dose-modified R-CHOP therapy, and five cases with R-miniCHOP therapy from 2012; two cases underwent palliative care. The International prognostic index (IPI) was High for nine cases, High-intermediate for four cases, Low-intermediate for four cases and Low for one case. The median duration of observation was 487 days, and the remission rate was 87%. The 2-year survival rate was 73%. Eight patients exhibited disease-free survival throughout the follow-up period, and 5 patients ultimately died. One of the fatalities was due to an infection as a consequence of small intestinal perforation after chemotherapy. After the chemotherapy was considered efficacious, six cases changed hospital to a local nursing facility, and were lost to follow-up. With respect to the QOL, while there was no apparent decrease in the social function compared with the patients who were younger than 80 years, physical function (PF) was impaired due to neuropathy (p=0.0006). Furthermore, after the chemotherapy, the mental component summary showed an upward trend for recovery of vitality and mental health (p=0.04), but the physical and role-social components remained impaired and were still below the normal-based scoring.Discussion: Thirty-four of 39 elderly patients aged 80 years or older received chemotherapy, and only one case experienced a treatment-related death. However, after chemotherapy, several cases intended to change the hospital to local nursing facilities, and it was not possible to investigate the prognosis, including recurrence. We also reported cases for which agreement was not obtained with respect to invasive biopsies, i.e., an abdominal operation. While the patients were stable psychologically, there was a severe decrease of physical function with respect to the QOL. Chemotherapy-induced neuropathy is included among the causative processes, and we should weigh the choice of chemotherapeutic agents that do not contribute to severe neuropathy. With sufficient supportive care, the chemotherapy could be administered safely and would be anticipated to be efficacious. However, invasive biopsy indicated an impossible case, and decrease of physical function, due to side effects, lowered the QOL. It is anticipated that future clinical studies will consider these factors. DisclosuresNo relevant conflicts of interest to declare.

The Incidence and the Risk Factors of Bowel Perforation Due to Chemotherapy in Gastrointestinal Diffuse Large B Cell Lymphoma

BACKGROUNDBowel perforation after chemotherapy is a serious life-threatening complication of diffuse large B cell lymphoma (DLBCL) involving gastrointestinal tract. R Vaidya et al reported that 9 % of patients with gastrointestinal lymphoma developed a perforation, of which 55% occurred after chemotherapy, and DLBCL was the most common lymphoma associated with perforation (R Vaidya et al Ann Oncol 2013). We assume that the dose reduction of chemotherapy may have advantages to reduce the risk of gastrointestinal perforation and shorten the duration of neutropenia. This study aimed to investigate the incidence of gastrointestinal perforation after chemotherapy, whether reduced dose intensity chemotherapy could reduce the risk of the bowel perforation and how therapeutic modalities influence on the prognosis. PATIENTS AND METHODSWe retrospectively reviewed the medical records of 348 consecutive patients who were diagnosed as having DLBCL at the Gifu University Hospital between August 2004 and April 2015. Eighty-six patients (86/348, 24.7%) were identified to have gastrointestinal involvement of DLBCL by biopsy. The prognosis of DLBCL patients with GI involvement was retrospectively investigated regarding treatments. RESULTSThe involved sites were gastric (51 patients, 48.1%), duodenal (7 patients, 6.6%), colorectal (6 patients, 5.7%), small intestine (36 patients, 34.0%) with duplicate counts permitted. Fourteen patients (14/86, 16.3%) were provided surgical treatment prior to chemotherapy since many of them had already suffered from serious complications such as ileus, perforation and bleeding. Sixty-five patients (65/86, 75.5%) received R-CHOP or CHOP like regimen ± radiation therapy as a first-line chemotherapy. As for remaining patients, two patients received R-hyperCVAD regimen because their histology were Burkitt like, and another patients received Rituximab ± other low dose chemotherapy for their frailness. The 45 patients (45/65, 69.2%) of them received reduced dose intensity (RDI) chemotherapy at the first course because increased risk of gastrointestinal perforation with chemotherapy was concerned about by endoscopic findings. The reduction rates of chemotherapy determined by the attending physician were approximately from 10% to 50%. Six patients (6/65, 9.23%) developed gastrointestinal perforation after chemotherapy (stomach 1, duodenum 0, small intestine 5, colon 0). Three of them received full dose chemotherapy at the time of small intestinal perforation including 2 patients who developed grade 4 neutropenia after the perforation. One of them died of infection after the perforation. The perforation rate was 15.0% in full dose chemotherapy group and 6.67% in the RDI chemotherapy group (p=0.361). The median day of perforation after initiation of chemotherapy was 21 days (range; 5-63 days). The small intestine was the most common site of perforation and 4 patients (4/5, 80%) had the ulcerative type lesions in their perforation site. CONCLUSIONSPrior to chemotherapy, risk of GI perforation should be evaluated. We consider that small intestinal ulcerative lesion is high risk of GI perforation. The RDI chemotherapy may be an optimal therapy for patients with primary GI DLBCL with high risk. Further and larger prospective study should be required to confirm this. DisclosuresNo relevant conflicts of interest to declare.

Ileal perforation and transanal protrusion of the peritoneal tube in a boy with a ventriculoperitoneal shunt and literature review

Ventriculoperitoneal shunting (VPS), a widely used procedure for treating hydrocephalus, may cause various complications, including mechanical failure, shunt infection, and intra-abdominal complications. Among these, intestinal perforation is rare. Patients suffering from intestinal perforation may be asymptomatic or present symptoms, such as abdominal pain, vomiting, fever, abdominal abscess, and peritonitis. However, such patients rarely manifest transanal protrusion of the peritoneal tube, which results in bowel perforation in the colon. In this report, we present the case of a 3-year-old boy with VPS-induced small-intestinal perforation and peritoneal-tube transanal protrusion. Additionally, a review of the literature on VPS-induced small-intestinal perforations revealed no similar cases.

Polyarteritis Nodosa Presenting as Small Intestinal Ulceration and Perforation

Polyarteritis Nodosa Presenting as Small Intestinal Ulceration and Perforation

International Association of Trauma and Surgical Intensive Care Symposium: Penetrating Trauma. Update on Penetrating Trauma.

Significant advances in the management of penetrating trauma have taken place over the past decade. Military experience has demonstrated the benefits of changes in our prehospital management and resuscitation strategies, and improving technology has allowed an evolution in diagnostic and therapeutic paradigms. In the end, however, there are fundamental principles that continue to guide how we approach the patient with penetrating injury. The trauma victim who suffers cardiopulmonary arrest is likely to die without immediate intervention. Dr. Civil and colleagues provide an overview of resuscitative thoracotomy in penetrating trauma, including indications, technical considerations, and outcomes. In addition, they discuss issues such as training, personnel, and location— pointing out that the capabilities in urban trauma centers in the US are not necessarily duplicated in hospitals worldwide. This is certainly a consideration in designing an institutional protocol for managing patients in extremis. Penetrating neurotrauma can be immediately lethal or leave the victim with devastating disability. Rosenfeld and colleagues provide an overview of penetrating and blast injury to the central nervous system. Blast injury and its sequelae are being seen with increasing frequency in the aftermath of military conflict. The authors emphasize the importance of aggressive resuscitation and correction of coagulopathy, and highlight the need for early operative intervention in order to optimize outcomes. On the other hand, they offer criteria for nonoperative management of penetrating injuries to the brain and spinal cord. Finally, the importance of early decompression for blast injuries is highlighted. In his paper on penetrating cervical trauma, Dr. Feliciano reviews the signs and symptoms of significant vascular or aerodigestive injury, and emphasizes that early operative intervention is most appropriate in symptomatic patients. Among patients without symptoms, he points out that serial clinical evaluation is accurate and that CT scanning does not improve on the accuracy. On the other hand, as he points out, CT scanning is likely to obviate the need for invasive testing in the patient with ‘‘soft’’ signs or equivocal exam findings. Finally, he offers valuable technical tips for the surgical management of cervical injuries. In ‘‘Laparoscopy in penetrating abdominal trauma,’’ Uranues and colleagues describe the benefits of employing technological advances in the diagnosis and management of abdominal trauma. As surgeons gain experience with laparoscopy, it can be relied upon to facilitate diagnosis of significant abdominal and thoracoabdominal injuries— particularly diaphragmatic lacerations, small intestinal perforation, and mesenteric hemorrhage. The reduced surgical morbidity and length of stay, and cost-effectiveness of this approach compared with laparotomy, make a compelling argument for laparoscopy as the preferred approach in the stable patient. This paper highlights the importance of trauma surgeons’ acquisition and maintenance of skills in the elective surgical realm, so that they may be applied in the emergency situation. A different, even less-invasive, approach to penetrating abdominal trauma is described by Biffl and Leppaniemi. The authors offer evidence that, in patients with anterior abdominal stab wounds, performing additional testing & Walter L. Biffl walter.biffl@dhha.org

A comparative study of small intestinal perforation secondary to foreign body and other non-traumatic causes.

Little was known about gastrointestinal perforation secondary to foreign body in adults, which was only documented by several case series reports. The aim of this study was to characterize it with comparative methods. A retrospective study was conducted on twenty patients with the diagnosis of gastrointestinal perforation secondary to foreign body between January 2003 and October 2013. The perforations were all located in the small intestine and compared to eighty-seven patients with non-traumatic small intestinal perforation. 35% of the patients in the foreign body group were over 65 years of age, which is much higher than the local elderly population ratio (p=0.002). In the foreign body group, more patients presented without diffuse abdominal physical signs (p=0.008) and preoperational CT scans had higher accuracy (p=0.027). Perforation repair was performed more often (p=0.024). Mean MPI was 19.9 and the morbidity rate was 35%, significantly lower than in the cases of other causes (p=0.001, 0.041). Mean duration of hospitalization was 11.5 days and was shorter compared to other causes (p=0.038). Clinical performance of small intestinal perforation secondary to foreign body is atypical, and preoperative diagnosis relies on CT scans. Primary perforation closure is safe and effective, and relatively better outcomes can be achieved.

外傷性小腸穿孔を契機に発見されたCrohn病の1例

外傷性小腸穿孔を契機に発見されたCrohn病の1例