PRESENTED BY: MENCHUKE JENNIFER NJILAH

1. A CASE STUDY REPORT ON HEMOPERITONEUM CARRIED OUT AT THE BAMENDA REGIONAL HOSPITAL DURING AN INTERNSHIP FROM 7 DECEMBER 2017 TO 7 JANUARY 2018 PRESENTED BY: MENCHUKE JENNIFER NJILAH 25 APRIL 2018 SUPERVISED BY DR MFONFU DANIEL

2. Definition of Hemoperitoneum: Hemoperitoneum is a medical condition in which there is collection of blood in the abdominal cavity specifically the peritoneal cavity (AUTHOR, YEAR). The peritoneal cavity is the space between the two peritoneal membranes which separate the abdominal wall from the abdominal organs. It is basically a fluid filled sac. The fluid present in the peritoneal cavity acts as a lubricant to reduce friction between the organs and also has anti-inflammatory properties.

3. The most commonly injured organs are the spleen, liver, retroperitoneal (external or posterior to the peritoneum), small bowel, kidneys, bladder, colerectum (related to the colon and/or rectum), diaphragm and pancreas. Men tend to be affected slightly more than women. (Wikipedia.2017) MOTIVATION FOR THE CASE The reason I chose this disease Hemoperitoneum was for me to know more about the disease and how to manage its emergency and to sensitize the population and especially travellers to evade/avoid conflict situations.

4. SOME CAUSES • Hemoperitoneum is caused by blunt abdominal trauma. • - In traumatic Hemoperitoneum: liver injury – spleen Bowel and mesenteric injuries, • In non-traumatic Hemoperitoneum, it may occur spontaneously or may be iatrogenic. • - Spontaneous Hemoperitoneum: - haemorrhage or rupture of an ovarian cyst - rupture of the gestational sac - an ectopic pregnancy - and bleeding from a vascular lesion such as arterial aneurysm. • - Iatrogenic Causes: Any surgical procedure performed w ithinthe peritoneal cavity may complicated by Hemoperitoneum.

5. Pathophysiology • Intra-abdominal injuries secondary to blunt force are attributed to collisions between the injured person and the external environment and due to acceleration and deceleration forces acting on the person’s internal organs

6. CLINICAL FEATURES • The initial clinical assessment of patients with blunt abdominal trauma is often difficult and notably inaccurate. The most reliable signs and symptoms to alert are: ( Legome et al., 2017] • Pain due to the inflammation of the peritoneal cavity; - Tenderness; Gastrointestinal haemorrhage • Hypovolemia • Evidence of peritoneal irritation • Distended abdomen • Dysphonia • Tiredness

7. DIAGNOSIS • Paracenthesis – (puncture of the abdomen and aspiration of blood that does not clot) is the first action to perform where there is no sonography facilities • Diagnostic pentoneal lavage is indicated for patient in the setting of blunt trauma with a spinal cord injury, • Computedtomography (CT) • An ultrasound is a procedure in which sound waves are used to produce images of the inside of the body. It helps to detect the presence of fluid/blood in the peritoneal cavity. • Magnetic resonance imaging (MRI) involves in the use of magnetic and radio waves to produce images of the inside of the body which can help detect hemoperitoneum. • Diagnostic or Exploratory laparotomy by creating a surgical incision into the abdomen to check the source of the bleeding ( Brasel, 1998)

8. TREATMENT • Surgical treatment • Paracenthesisinvolves inserting cavity. The plunger is then pulled back in order to draw the fluid from inside the peritoneal cavity into the syringe. • Ligationinvolves clamping or tying off a blood vessel that is ruptured and causing bleeding. • Cauterizationinvolves the burning of tissues in order to close the tissue off to stop the bleeding process. • Medicationscoagulants medication, drugs that help to clot the blood can be use to stop bleeding. • Laparotomyinvolves making an incision into the abdomen to drain fluids that have accumulated in the abdomen. - Blood Transfusion is an initial management if patient is in haemorrhagic shock.

9. Complication Haemorrhagic shock, anaemia The demographic identity of the case on admission A 20years old male living at mile 8 Mankon, Catholic by faith and a businessmen, Cameroonian by nationality of blood group A, admitted in E- ward on Bed 29.

10. Condition of arrival of the patient of the hospital From the patient hospital book, patient walked into the casualty on the 9/12/2017 at 2pm conscious and assisted by the mother presenting with a stabbed wound to the (R) costal region alleged to have been assaulted in Nigeria, referred case from Sacred Heart Catholic Hospital Nigeria with impressive diagnosis of peritonitis secondary to stabbing plus Hemoperitoneum

11. examination history of present illness 20years old boy presented 4days following a penetrating abdominal trauma which started on the 15/12/17 in Nigeria, as patient do complaint of being misunderstood to someone else by a businessman who had a quarrel with his sales boy on settlement at the bus station on his return to Cameroon, so he was stabbed by the businessman, and he was rushed to a near by hospital where it was been sutured and situation got worst, with generalized abdominal pain, distended abdomen but no constipation and vomiting until the progress of swelling and pain prompt consultation to a catholic hospital at Nigeria where he was referred to Cameroon.

12. Provisional diagnosis by MD of casualty on admission Peritonitis secondary to stabbed wound Medical prescription and treatment on admission by Dr. at casualty 1) Normal Saline 1000cc/daily 2) Ceftriaxone inj; 1g IV bd 3) Metronidazale infusion; 100mg IV 8hrly 4) Trabar100mg inj; 1A IV Bd 5) Cimetidine inj; 1A IV 8hrly

13. Description of the surgical Procedure Surgery started at 2:50 pm on 20/12/17 with an exploratory laparotomy indicated for penetrating abdominal trauma with signs of Hemoperitoneum. Surgeon –Dr x Assitant surgeon (nurse) Anaesthesia - General and an Anaesthetist Findings Massive Hemoperitoneum with a lacerated liver of 4 cm long with no perforation in the intestine. The surgery ended at 15:20 pm with patient still unconscious but the surgery was successful, and patient was transferred to the reanimation.

14. Example of drug chart rest in the report

16. Example of nursing care plan – rest in the report

19. Side effects observed on the case and management With Ceftriaxone - Vomiting and nauseas: medication was given slowly to avoid vomiting, patient was educated and ask to rest. DISCHARGE SUMMARY Diagnosis on admission : Peritonitis secondary to stabbed ward Diagnosis on discharge: Hemoperitoneum from penetrating thoracoabdominal trauma + (R) henmothorax+ psoas (thigh abscess) 5.3 Treatment received (1) Geloplasma; Infusion start (2) Normal saline 0.9% 1000c 24hrly (3) CeftriaxoneIginj / 24hrly

20. (4) Metronidazole 100mg / 8hrly 1 perf (5) Gentanycin 80mg / 1 AP 24hrly (6) Cimetidineinj 200mg 1 AP 8hrly (7) Tramadolinj 1 A 12hrly (8) Paracetamol inj 300mg 1AP Prn (9) Novagin (10) Glucose % 500cc R/L 500cc (11) B pint of blood transfused 5.4 Response to treatment Better 5.5 Condition on discharge - Ptdischarged on 9/1/18 better, wound ok, granulation ok and needed dressing after 2 days and pale looking. - Home treatment Ibuprofen 400mg / PO ; 2 – 2 – 2 / day / 7 days Ranfeon/ PO 50mg ; 1 – 0 – 1 / day / 30days Nitroflurontonine / PO 50mg , 2 – 2 – 2 / day / 10days

21. Advice on discharge - Ptshould not do hard work. - Ptshould have rest for 6mtus before carrying out his business, and in case of any problem let him rush back to the hospital for proper check. - Ptshould take his medication as prescribed, even if he feels better he should not stop till the prescribed dose is finished the should take with enough water after meal - Patient should avoid trouble situations especially when he travels

22. 4 Conclusion The case study on Hemoperitoneum was healed and it is advisable to avoid conflict situations especially during travelling to foreign countries

23. THANKS BE TO GOD!