CASE PRESENTATION

1. CASE PRESENTATION PREPARED BY: SANDHYA KS

2. DEMOGRAPHIC DATA • NAME: AH • AGE: 25 yrs old • SEX: Male • MR NO.: 189691 • NATIONALITY: Bangladeshi • DIAGNOSIS: Small bowel perforation with peritonitis • CHIEF COMPLAINTS: complaint of severe abdominal pain with vomiting • NAME OF SURGERY: Exploratory laparotomy and small bowel resection with Anastomosis • DATE OF ADMISSION: 10/01/13 • DATE OF SURGERY: 11/01/2013 • DATE OF DISCHARGE: 18/01/2013

3. GENERAL • Patient is intubated. • Looks weak and fatigue. • Unable to mobilize. • Upper teeth fracture. • Two drainage tubes from both sides of abdomen.

4. SKIN • Skin is warm. • Post operative scar present on abdomen. • Noted abrasion on upper and lower extremities. • Post operative scar on right leg.

5. HEAD and NECK • Hair is equally distributed. • Absence of dandruff. • Abrasions on face. • Patient’s pinna is same colour as fascial skin aligned with eye level. • Lips are pink but swollen. • Upper teeth fracture seen. • No lymph node enlargement. • CVP line present.

6. CARDIOVASCULAR • Old RTA with chest trauma • Airway Adequate • Heart sound : s1 and s2 normal • Upon auscultation his BP is 120/80mmHg • Pulse rate-66/mts • Lungs – bilateral vescicular sound present.

7. THORAX • Thorax is sympathetic on inspection

8. Genito urinary system With Foleys catheter FG.16present

9. Gastrointestinal System • Patient is old RTA with abdominal trauma tenderness present. • Two drainage tubes present from both sides of abdomen.

10. MUSCULOSKELETAL SYSTEM • Unable to mobilize his right lower limb • Has pain during examination • Cannot perform ADL • Tenderness at the site of fracture • Visible deformity • Lower extremities appears shortened

11. NEUROLOGIC • Patient is on ventilator under sedation • Old RTA with spine fracture • GCS 15/15

12. PATIENT HISTORY PAST MEDICAL HISTORY Patient is old RTA with polytrauma • Poor lung condition • Fracture tibia and thoracic spine • ORIF tibia done two months ago

13. PRESENT MEDICAL HISTORY • Patient is presented with post exploratory laparotomy with small bowel resection with anastomosis.

14. PRESENT SURGICAL HISTORY • He undergone exploratory laparotomy and small bowel resection with anastomiosis done under general anesthesia on 11/01/13

15. PAST SURGICAL HISTORY He undergone ORIF tibia done under general anesthesia on 01/11/12.

16. VITAL SIGNS • BP- 120/86mmhg • PR- 66 bpm • Temperature- 36.4C • SPO2- 98%

17. MEDICATION

18. INVESTIGATIONS

19. INTRODUCTION • small intestine (or small bowel) is the part of the gastrointestinal tract following the stomach and followed by the large intestine, and is where much of the digestion and absorption of food takes place. • A bowel resection is a surgical procedure in which a part of the large or small intestine is removed. • It may be performed due to cancer, necrosis, enteritis, diverticular disease, or a block in the intestine due to scar tissue. Other reasons to perform bowel resection include ulcerative colitis, traumatic injuries, precancerous polyps, and familial polyposis.

20. ANATOMY AND PHYSIOLOGY

21. ANATOMY AND PHYSIOLOGY

23. DISEASE CONDITION: Peritonitis • Peritonitis is an inflammation of the peritoneum, the thin tissue that lines the inner wall of the abdomen and covers most of the abdominal organs. Peritonitis may be localized or generalized, and may result from infection or from a non-infectious process.

24. The main manifestations of peritonitis are acute abdominal pain, abdominal tenderness, and abdominal guarding, which are exacerbated by moving the peritoneum, e.g., coughing (forced cough may be used as a test), flexing one's hips, or eliciting the Blumberg signplace). The presence of these signs in a patient is sometimes referred to as peritonism. The localization of these manifestations depends on whether peritonitis is localized (e.g., appendicitis or diverticulitis before perforation), or generalized to the whole abdomen. In either case, pain typically starts as a generalized abdominal pain (with involvement of poorly localizing innervations of the visceral peritoneal), and may become localized later (with the involvement of the somatically innervated parietal peritoneal layer). Peritonitis is an example of an acute abdomen.

25. COLLATERAL MNIFESTATIONS • Diffuse abdominal rigidity ("washboard abdomen") is often present, especially in generalized peritonitis • Sinus tachycardia • Development of ileus paralyticusi.e., intestinal paralysis), which also causes nausea, vomiting and bloating

26. INFECTED PERITONITIS • Perforation of part of the gastrointestinal tract is the most common cause of peritonitis. Examples include perforation of the distal esophagus (Boerhaave syndrome), of the stomach (peptic ulcer, gastric carcinoma), of the duodenum (peptic ulcer), of the remaining intestine (e.g., appendicitis, diverticulitis, Meckl diverticulum, inflammatory bowel disease (IBD), intestinal infarction, intestinal strangulation, colorectal carcinoma, meconium peritonitis), or of the gallbladder (cholecystitis

27. Other possible reasons for perforation include abdominal trauma, ingestion of a sharp foreign body (such as a fish bone, toothpick or glass shard), perforation by an endoscope or catheter, and anastomotic leakage. The latter occurrence is particularly difficult to diagnose early, as abdominal pain and ileus paralyticus are considered normal in patients who have just undergone abdominal surgery. In most cases of perforation of a hollow viscous, mixed bacteria are isolated; the most common agents include Gram-negative bacilli (e.g., Escherichia coli) and anaerobic bacteria (e.g., Bacteroidesfragilis). Fecal peritonitis results from the presence of feces in the peritoneal cavity. It can result from abdominal trauma and occurs if the large bowel is perforated during surgery.

28. Disruption of the peritoneum, even in the absence of perforation of a hollow viscus, may also cause infection simply by letting micro-organisms into the peritoneal cavity. Examples include trauma, surgical wound, continuous ambulatory peritoneal dialysis, and intra-peritoneal chemotherapy are possible, including fungi such as Candida. • Spontaneous bacterial peritonitis (SBP) is a peculiar form of peritonitis occurring in the absence of an obvious source of contamination. It occurs in patients with ascites, in particular, in children. See the article on spontaneous bacterial peritonitis for more information.

29. Intra-peritoneal dialysis predisposes to peritoneal infection (sometimes named "primary peritonitis" in this context). • Systemic infections (such as tuberculosis) may rarely have a peritoneal localization.

30. Non-infected peritonitis • Leakage of sterile body fluids into the peritoneum, such as blood (e.g., endometriosis, blunt abdominal trauma), gastric juice (e.g., peptic ulcer, gastric carcinoma),bile (e.g., liver biopsy), urine (pelvic trauma), menstruum (e.g., salpingitis), pancreatic juice (pancreatitis), or even the contents of a ruptured dermoid cyst. It is important to note that, while these body fluids are sterile at first, they frequently become infected once they leak out of their organ, leading to infectious peritonitis within 24 to 48 hours. • Sterile abdominal surgery, under normal circumstances, causes localized or minimal generalized peritonitis, which may leave behind a foreign body reaction and/or fibrotic adhesions. However, peritonitis may also be caused by the rare case of a sterile foreign body inadvertently left in the abdomen after surgery (e.g., gauze, sponge). • Much rarer non-infectious causes may include familial Mediterranean fever, TNF receptor associated periodic syndrome, porphyria, and systemic lupus erythematosus.

31. DIAGNOSIS • A diagnosis of peritonitis is based primarily on the clinical manifestations described above. If peritonitis is strongly suspected, then surgery is performed without further delay for other investigations. Leukocytosis, hypokalemia, hypernatremia, and acidosis may be present, but they are not specific findings. Abdominal X-rays may reveal dilated, edematous intestines, although such X-rays are mainly useful to look for pneumo peritoneum, an indicator of gastrointestinal perforation. The role of whole-abdomen ultrasound examination is under study and is likely to expand in the future. Computed tomography (CT or CAT scanning) may be useful in differentiating causes of abdominal pain. If reasonable doubt still persists, an exploratory peritoneal lavage or laparoscopy may be performed. In patients with ascites, a diagnosis of peritonitis is made via paracentesis(abdominal tap): More than 250 polymorphonuclet cells per μL is considered diagnostic. In addition, Gram stain and culture of the peritoneal fluid can determine the microorganism responsible and determine their sensibility to antimicrobial agents.

32. PATHOLOGY • In normal conditions, the peritoneum appears greyish and glistening; it becomes dull 2–4 hours after the onset of peritonitis, initially with scarce serous or slightly turbid fluid. Later on, the exudate becomes creamy and evidently suppurative; in dehydrated patients, it also becomes very inspissated. The quantity of accumulated exudates varies widely. It may be spread to the whole peritoneum, or be walled off by the omentum and viscera. Inflammation features infiltration by neutrophils with fibrino-purulent exudation.

33. TREATMENT • Depending on the severity of the patient's state, the management of peritonitis may include: • General supportive measures such as vigorous intravenous rehydration and correction of electrolyte disturbances.

34. ANTIBIOTICS Antibiotics are usually administered intravenously, but they may also be infused directly into the peritoneum. The empiric choice of broad-spectrum antibiotics often consist of multiple drugs, and should be targeted against the most likely agents, depending on the cause of peritonitis (see above); once one or more agents are actually isolated, therapy will of course be targeted on them.

35. EMPIRIC THERAPY • Gram positive and gram negative organisms must be covered. Out of the Cephalosporin, cefoxitin and cefotecan can be used to cover gram positives, gram negatives, and anaerobes. Beta-lactams with beta lactamase inhibitors can also be used, examples include ampicillin/sulbactam, piperacillin/tazobactam, and ticarcillin/clavulanate.[2]Carbapenems are also an option when treating primary peritonitis as all of the carbapenems cover gram positives, gram negatives, and anaerobes except for ertapenem. The only fluoroquinolone that can be used is moxifloxacin because this is the only fluoroquinolone that covers anaerobes. Finally, tigecycline is a tetracycline that can be used due to its coverage of gram positives and gram negatives. Empiric therapy will often require multiple drugs from different classes

36. SURGERY • (laparotomy) is needed to perform a full exploration and lavage of the peritoneum, as well as to correct any gross anatomical damage that may have caused peritonitis.[3] The exception is spontaneous bacterial peritonitis, which does not always benefit from surgery and may be treated with antibiotics in the first instance.

37. PROGNOSIS • If properly treated, typical cases of surgically correctable peritonitis (e.g., perforated peptic ulcer, appendicitis, and diverticulitis) have a mortality rate of about <10% in otherwise healthypatients, which rises to about 40% in the elderly, and/or in those with significant underlying illness as well as in cases that present late (after 48 hours). If untreated, generalized peritonitis is almost always fatal.

38. COMPLICATIONS • Sequestration of fluid and electrolytes, as revealed by decreased central venous pressure, may cause electrolyte disturbances, as well as significant hypovolemia, possibly leading to shock and acute renal failure. • A peritoneal abscess may form (e.g., above or below the liver, or in the lesser omentum • Sepsi may develop, so blood cultures should be obtained.

39. DISEASE CONDITION –GASTROINTESTINAL PERFORATION • Gastrointestinal perforation is a complete penetration of the wall of the stomach, small intestine or large bowel, resulting in intestinal contents flowing into the abdominal cavity. Perforation of the intestines results in the potential for bacterial contamination of the abdominal cavity (a condition known as peritonitis). Perforation of the stomach can lead to a chemical peritonitis due to leaked gastric acid. Perforation anywhere along the gastrointestinal tract is a surgical emergency.

40. SIGNS AND SYMPTOMS • Sudden attack of pain in epigastrium to the right of midline • burning pain in epigastria, flatulence and dyspepsia • rigidity of abdomen • tenderness, and rebound tenderness • nausea and vomiting • fever and or chills.

41. CAUSES • gastric ulcer • appendicitis • gastrointestinal cancer • diverticulitis • superior mesenteric artery syndrome  • trauma, ascariasis • Typhoid fever • non-steroidal anti-inflammatory drugs •  ingestion of corrosives 

42. DIAGNOSIS • x-rays (free gas/air may be visible in the abdominal cavity) • computed tomography • White blood cells are often • ridged abdomen on palpation

43. SURGICAL INTERVENTIONS • exploratory laparotomy and closure of perforation • If patient is in case nontoxic and clinically stable, they can be treated with intravenous fluids, antibiotics, nasogastric aspiration and bowel rest

44. EXPLORATORY LAPAROTOMY • Definition • A laparotomy is a large incision made into the abdomen. Exploratory laparotomy is used to visualize and examine the structures inside of the abdominal cavity.

45. PURPOSE • Exploratory laparotomy is a method of abdominal exploration, a diagnostic tool that allows physicians to examine the abdominal organs. The procedure may be recommended for a patient who has abdominal pain of unknown origin or who has sustained an injury to the abdomen. Injuries may occur as a result of blunt trauma (e.g., road traffic accident) or penetrating trauma (e.g., stab or gunshot wound). Because of the nature of the abdominal organs, there is a high risk of infection if organs rupture or are perforated. In addition, bleeding into the abdominal cavity is considered a medical emergency. Exploratory laparotomy is used to determine the source of pain or the extent of injury and perform repairs if needed.

46. Laparotomy may be performed to determine the cause of a patient's symptoms or to establish the extent of a disease. For example, endometriosis is a disorder in which cells from the inner lining of the uterus grow elsewhere in the body, most commonly on the pelvic and abdominal organs. Endometrial growths, however, are difficult to visualize using standard imaging techniques such as x ray, ultrasound technology, or computed tomography (CT) scanning. Exploratory laparotomy may be used to examine the abdominal and pelvic organs (such as the ovaries, fallopian tubes, bladder, and rectum) for evidence of endometriosis. Any growths found may then be removed.

47. Exploratory laparotomy plays an important role in the staging of certain cancers. Some other conditions that may be discovered or investigated during exploratory laparotomy include: • cancer of the abdominal organs • peritonitis (inflammation of the peritoneum, the lining of the abdominal cavity) • appendicitis (inflammation of the appendix) • pancreatitis (inflammation of the pancreas) • abscesses (a localized area of infection) • adhesions (bands of scar tissue that form after trauma or surgery) • diverticulitis (inflammation of sac-like structures in the walls of the intestines) • intestinal perforation • ectopic pregnancy (pregnancy occurring outside of the uterus) • foreign bodies (e.g., a bullet in a gunshot victims • Internal bleeding.

48. INCISION • Once an adequate level of anesthesia has been reached, the initial incision into the skin may be made. A scalpel is first used to cut into the superficial layers of the skin. The incision may be median (vertical down the patient's midline), paramedian (vertical elsewhere on the abdomen), transverse (horizontal), T-shaped, or curved, according to the needs of the surgery. The incision is then continued through the subcutaneous fat, the abdominal muscles, and finally, the peritoneum. Electrocautery is often used to cut through the subcutaneous tissue as it During a laparotomy, and an incision is made into the patient's abdomen (A). Skin and connective tissue called fascia is divided (B). The lining of the abdominal cavity, the peritoneum, is cut, and any exploratory procedures are undertaken (C). To close the incision, the peritoneum, fascia, and skin are stitched (E) has the ability to stop bleeding as it cuts. Instruments called retractors may be used to hold the incision open once the abdominal cavity has been exposed.

50. ABDOMINAL EXPLORATION • The surgeon may then explore the abdominal cavity for disease or trauma. The abdominal organs in question will be examined for evidence of infection, inflammation, perforation, abnormal growths, or other conditions. Any fluid surrounding the abdominal organs will be inspected; the presence of blood, bile, or other fluids may indicate specific diseases or injuries. In some cases, an abnormal smell encountered upon entering the abdominal cavity may be evidence of infection or a perforated gastrointestinal organ