Case report - PowerPoint PPT Presentation

1 / 96
About This Presentation
Title:

Case report

Description:

... with perforated typhoid enteritis treated at the Baptist ... Enteroinvasive E coli. E coli 0157: H7. Salmonella. Yersinia enterocolitica. Aeromonas species ... – PowerPoint PPT presentation

Number of Views:1466
Avg rating:3.0/5.0
Slides: 97
Provided by: foss7
Category:

less

Transcript and Presenter's Notes

Title: Case report


1
Case report
  • ??910529
  • ????????
  • ????????

2
  • 91-04-23 415 am
  • ?, ??86011, ?
  • BT 36.8?, PR 96, RR 16, SaO2 98, BW 22kg
  • ??abdominal pain and diarrhea
  • Triage 3

3
  • CC abdominal pain since 300 am
  • PI Fever 2 days ago and subside yesterday, sore
    throat and intermittent abdominal pain for 2
    days. Loose stool passage for 1 day? visited LMD,
    tonsilitis and oral ulcer was told. Received iv
    hydration and symptoms relieved then.

4
  • On 910423, severe abdominal pain occurred in the
    early morning and he was sent to our ED for help.
    His father noted 2 times of diarrhea (first
    watery, then loose stool) without vomiting.

5
  • Past history
  • Pneumonia 3-4 yrs ago
  • no major medical or surgical history, no
    allergic history

6
PE
  • Consciousness clear, acute ill looking
  • HEENT pink, not icteric
  • Chest BS clear
  • Abdomen diffuse tenderness, tympanic(),
    rebounding tenderness(/-), guarding() mild
  • Flank and back not tender
  • Ext free
  • Impression???

7
  • Impression
  • 1. acute tonsilitis 2 days
  • 2. Acute abdomen, r/o appendicitis

8
Order sheet
  • Volteran 1 supp st
  • NPO

9
Re-do PE after medication
  • Patient said his pain was mild relieved
  • Still painful, tender and guarding
  • Impression
  • peritonitis, cause to be determined

10
Order sheet 544 am
  • KUB

11
620 am
  • Imp hollow organ perforation
  • Bedside echo
  • Consult Pediatrics
  • IVF 0.33 GS run 60cc/hr
  • WBC,DC,Hb,PLT
  • 0055, amylase
  • CXR upright

12
629 am
  • Bedside echo pseudokidney sign at RLQ
  • R/I intussusception
  • P
  • 1. Iv hydration
  • 2. Lab data
  • 3. CT of abdomen
  • 4. Admission

13
Pediatrics note 700 am
  • S/O URI amd sore throat being told for 2 days.
    Intermittent abdominal pain for 2 days, fever(-)
  • Loose stool passage for 1 day
  • Previous medication received at LMD
  • PE
  • HR 98, BP 110/60 mmHg

14
Pediatrics note 700 am
  • HEENT mild throat injection
  • Chest clear BS
  • Abdomen marked abdominal distension
  • tenderness(), muscle guarding(), rebounding
    pain(), hyperactive bowel sounds
  • Ext freely movable, Skin rash(-)

15
Pediatrics note 700 am
  • KUB visible free air, portal air
  • CSR free air below bilateral diaphragm
  • Abdominal echo markded ileus, minimal ascites
  • Imp GI perforation and peritonitis

16
Pediatrics note 700 am
  • Plan
  • 1. Closely note for vital signs
  • 2. Adequate hydration
  • 3. Consult pediatric surgeon
  • 4. Empiric antibiotics
  • 5. On critical condition

17
Order sheet 713 am
  • NS 200cc st
  • Cefamezine 500 mg iv st
  • GM 40 mg ivd st
  • Metronidazole 220 mg ivd st
  • On critical
  • Abdominal CT
  • Consult Ped surgen
  • Keto 0.5 amp ivd st

18
718 am Lab Data
  • Glu 107, GOT 16, BUN 14, Cr 0.6, Na 144, K 3.9,
    Amylase 68, lipase 61
  • Hb 11.6
  • WBC 3600, seg 53, lym 40.4
  • PLT 301000

19
Ped Surgeon consultation note 730 am
  • 5 y/o boy
  • 4/21
  • abdominal pain- mild, seen at LMD, given iv drip
  • Resolved shortly there after
  • 4/22
  • Feeding well, good activity
  • 4/23 3 am severe abdominal pain , crying
  • No diarrhea,/nausea, no fever, admitted for
    pneumonia 3-4 yrs ago
  • No surgical history

20
Ped Surgeon consultation note 730 am
  • PE no fever
  • RR 18, BP 110/60
  • Guarding, peritonitis, mild rebounding pain, mild
    distension
  • Na 144, K 3.9, Hb 11.5, WBC 3600, Seg 55
  • KUB,CXR free air, bilateral subphrenic space
  • A hollow organ perforation
  • P IVF, antibiotics, Explain to Dad, op and
    anesthesia risk, Suggest laparotomy

21
755 am
  • Vital signs BT 37.2 ?, PR 128, RR 16, BP 97/60
    mmHg

22
800 am
  • DC abdominal CT (??????????)
  • But patient was sent to OR at 855 am

23
Op finding
  • 2 perforation holes on the posterior wall of T
    colon and large amount of fecal fluid
  • Procedure
  • 1. Exploratory laparotomy
  • 2. Primary repair of colon
  • perforation
  • 3. Drainage

24
Discharge diagnosis
  • Acute enterocolitis with transverse colon
    perforation and peritonitis, s/p laparotomy,
    primary repair with drainage

25
  • Thanks!!

26
Paper 1
  • Factors associated with intestinal perforation in
    children's non-typhi Salmonella toxic megacolon.
  • Pediatr Infect Dis J 2000 Dec19(12)1158-62
    Department of Pediatrics, Chang Gung Children's
    Hospital, Taoyuan, Taiwan

27
BACKGROUND
  • To evaluate the risk factors for intestinal
    perforation in children with toxic megacolon
    caused by non-typhi Salmonella infection.

28
METHODS
  • 11-year period, reviewed the records of children
    treated for non-typhi Salmonella infection.
  • All had positive stool culture for non-typhi
    Salmonella and were treated with intravenous
    ceftriaxone during hospitalization.

29
  • Clinical data reviewed included
  • demographic features,
  • clinical manifestations,
  • laboratory findings,
  • radiologic findings,
  • microbiology,
  • therapeutic effect of hydration
  • rectal tube placement
  • operative findings.

30
  • toxic megacolon
  • toxic appearance
  • Diarrhea
  • high fever (gt39 degrees C)
  • marked colon dilatation with maximal diameter gt
    1.5 times the width of the vertebra body of the
    first lumbar spine (L1-VB).

31
  • patients were divided into two groups for
    analysis P group? complicated with intestinal
    perforation
  • NP group? without intestinal perforation.
  • Statistical analyses were conducted with chi
    square tests and multiple logistic regression.

32
RESULTS
  • total 75 patients
  • P group, 27 patients NP group, 48 patients
  • ages 4 months to 6 years

33
  • 7 variables were found to be significantly
    associated with intestinal perforation
  • age gt1 year
  • fever gt5 days
  • ratio of immature to total neutrophils gt20
  • serum CRP gt200 mg/l
  • colon diameter gt2.5 times the width of L1-VB
  • inadequate early hydration
  • delay in rectal tube insertion.

34
the most significant factors associated with
intestinal perforation With multivariate
analysis.
  • age gt1 year
  • serum CRP gt200 mg/l
  • colon diameter gt2.5 times of width of L1-VB
  • inadequate early hydration
  • delay in rectal tube insertion

35
CONCLUSION
  • Identification of patients with toxic megacolon ?
    intestinal perforation
  • Early effective fluid resuscitation and rectal
    tube insertion may be helpful to prevent the
    occurrence of intestinal perforation

36
Paper 2
  • Am J Dis Child 1984 Nov138(11)1058-61
  • Primary peritonitis in previously healthy
    children.
  • Freij BJ, Votteler TP, McCracken GH Jr.

37
  • In a review of 22 years of clinical experience,
    we found seven previously healthy children with
    primary peritonitis.
  • The diagnosis was made at laparotomy in all
    patients.
  • Their symptoms included diffuse abdominal pain,
    fever, vomiting, and diarrhea.

38
  • Abdominal tenderness was maximal in the right
    lower quadrant in five children
  • Streptococcus pneumoniae ? in three patients
  • group A beta-hemolytic Streptococcus in one
    patient
  • The remaining three patients all had prior
    antibiotic therapy, and peritoneal fluid cultures
    were sterile.

39
  • All children had a prompt response to treatment
    with antibiotics and recovered without
    complications.
  • Long-term follow-up (4 1/2 to 15 years) was
    available for three patients all three remained
    healthy.

40
Paper 3
  • Perforation of toxic megacolon in non-typhoid
    Salmonella enterocolitis spares young infants and
    is immune-mediated
  • Chang Gung Children's Hospital
  • Ped Surg 2002

41
Introduction
  • Toxic megacolon dilatation of the colon over
    6 cm and clinical toxicity,
  • Since then, it has also been related to a number
    of intestinal infectious diseases such as typhoid
    fever, non-typhoidel salmonellosis, and
    yersiniasis .
  • Some cases of TM are complicated by intestinal
    perforation, which is life-threatening and
    usually necessitates surgical repair

42
Materials and methods
  • The medical records of 86 children with
    culture-confirmed non-typhoid Salmonella
    enterocolitis complicated by TM during a 13-year
    period (1988-2000)
  • retrospectively analyzed
  • TM toxic appearance, dysentery, fever, and
    marked colon dilatation
  • a maximal colon diameter over 1.5 times the width
    of the body of the 1st lumbar spine on a plain
    abdominal radiograph.

43
  • Of these patients, 28 were less than 1 year of
    age (9.4 2.3 months) and 58 were over 1 year
    (25.6 12.1 months).
  • All patients received rectal as well as
    nasogastric tube decompression, hydration, and
    parenteral antibiotic therapy
  • For analysis of cytokines, serum samples were
    collected during the acute illness (usually
    within 3 days after admission)
  • interleukin-1 (IL-1 ) and tumor necrosis factor-
    (TNF )

44
Results
  • 86 children who had TM following non-typhoid
    Salmonella infection, perforation occurred
    significantly less commonly in those under 1 year
    of age (4/28 vs 26/58, 2 4.85, P 0.0277)
  • while the duration of symptoms, average colon
    diameter, leukocyte count, and serum C-reactive
    protein level among patients in the two age
    groups were not statistically different (data not
    shown)

45
  • Sera from 11 children with TM who were treated
    during 1999-2000 were prospectively collected for
    cytokine analysis
  • 5 were less than 1 year of age.
  • Only 1 of the 5 infants, in contrast to 3 of the
    6 older children, had a bowel perforation

46
  • Perforation invariably occurred in the cecum (3)
    or ascending colon (1)
  • Ten age-matched patients with uncomplicated
    Salmonella enterocolitis were included as
    controls.
  • IL-1 , 170.48 55.75 pg/ml vs 26.99
    32.10 pg/ml, P 0.0014
  • TNF , 67.03 24.68 pg/mL vs 26.80 18.96 pg/ml,
    P 0.0219
  • both by two-tailed Student t-test

47
(No Transcript)
48
Discussion
  • non-typhoid salmonellosis intestinal perforation
    rate is about 1
  • Among our patients with TM following non-typhoid
    Salmonella infection, intestinal perforation was
    much more common in patients aged over 1 year.

49
  • Children over 1 year of age had a stronger
    inflammatory response characterized by higher
    circulating concentrations of cytokines.
  • production of cytokines is related to the
    intestinal Peyer's patches
  • The stronger inflammatory stimulation in older
    children following Salmonella infection may
    perpetuate the development of TM with subsequent
    perforation

50
  • It appears that the pathogenesis of TM caused by
    non-typhoid Salmonella is similar to that caused
    by S. typhi.
  • Corticosteroids effective in the presence of
    coma, shock, and severe bowel hemorrhage and
    perforation.
  • ?immunotherapy for older children with TM
    following non-typhoid Salmonella infection in
    order to prevent intestinal perforation

51
Paper 4
  • World J. Surg. 22319-323 (1998)
  • Typhoid Intestinal Perforations in Nigerian
    Children
  • Donald E. Meier, John L. Tarpley

52
  • retrospective analysis
  • 75 children with perforated typhoid enteritis
    treated at the Baptist Medical Centre in
    Ogbomoso, Nigeria over a 4-year period.
  • The mean age was 11.4 years.
  • The usual symptoms were fever and abdominal pain,
    with a mean duration of 10.5 days.

53
  • The diagnosis of perforation was usually based on
    the history and physical examination alone.
  • The time interval from hospital presentation to
    operation was 11 hours, during which intravenous
    crystalloid and antibiotics were administered.

54
  • Among the 75 children, 53 (71) had a single
    perforation, and 22 had multiple perforations.
  • Debridement and two-layered closure was performed
    in 71 (95) and resection with anastomosis in 4
    (5).
  • Ileus resolution was usually not complete until
    the eighth postoperative day, and the mean time
    until the surviving children were afebrile was 10
    days.

55
  • Complications other than death occurred in 7 (9)
    children, and there were 15 deaths (20
    mortality)
  • All deaths were attributed to overwhelming
    sepsis, and all but one of the deaths occurred
    during the first 72 postoperative hours.
  • The only factor statistically significant as a
    predictor of mortality was the duration of
    abdominal pain

56
Textbook
  • Cause of Peritonitis
  • Specific topics about Peritonitis
  • Toxic megacolon
  • bacterial causes of inflammatory diarrhea

57
Cause of Peritonitis
  • Perforation of a viscus into the peritoneal
    cavity
  • Trauma
  • Infected intraperitoneal blood
  • Foreign bodies
  • Strangulating intestinal obstruction
  • Pancreatitis
  • Pelvic inflammatory disease (PID)
  • vascular catastrophes (mesenteric thrombosis or
    embolism)

58
Diagnosis
  • Plain abdominal x-rays should be taken in both
    supine and upright positions.
  • Occasionally, the possibility of a primary
    peritonitis may seem high enough to warrant
    aspiration and Gram stain of the peritoneal fluid
  • Laparotomy is the most important diagnostic
    measure

59
Perforated abdominal esophagus
  • may develop from iatrogenic perforations above or
    below the diaphragm.
  • Forceful vomiting with a full stomach may cause
    esophageal rupture (Boerhaave's syndrome)
  • Pain in the left upper quadrant, left chest, or
    shoulder after any of these occurrences
  • ? order an immediate barium or meglumine
    diatrizoate (Gastrografin) swallow.
  • If a perforation is noted, immediate operation is
    necessary

60
PPU
  • cause the most serious cases of peritonitis
  • mortality rate nearly 20.
  • There may be a history of peptic ulcer disease,
    but in about 33 of cases,

61
PPU
  • the first symptom is a sudden attack of severe
    epigastric pain.
  • A patient examined shortly after onset may be
    relatively free of pain and show only mild
    tenderness and diminished or absent peristalsis.
  • However, within a few hours, vomiting,
    tenderness, and spasm, either in the epigastrium
    or over the whole abdomen, develop.

62
PPU
  • upright abdominal x-ray taken 6 h after
    perforation shows air under diaphragm in about
    50 of cases
  • If the diagnosis is in doubt, meglumine
    diatrizoate (Gastrografin) passed into the
    stomach through an inlying nasogastric tube will
    demonstrate the perforation.
  • (Meglumine diatrizoate does not irritate the
    peritoneum as does standard barium.)

63
PPU
  • The earlier an operation is performed, the
    greater the chance of success.
  • simple closure of the perforation or definitive
    operation for the ulcer disease (vagotomy with
    gastric resection or pyloroplasty)

64
Perforated intestine
  • may arise from strangulating obstruction and
    perforated Meckel's diverticulum.
  • The diagnosis of peritonitis must be based on
    clinical symptoms of severe abdominal pain,
    tenderness, and absent peristalsis.
  • X-rays are of little value
  • Gangrene and perforation can occur within 6 h, so
    exploration must be performed expeditiously.

65
Perforated appendix
  • occur at any age but is the most common cause of
    peritonitis in children and young adults
  • In children, because of a poorly developed
    omentum, peritonitis is likely to be generalized
  • in adults, local peritonitis and abscess
    formation are more common.

66
Perforated appendix
  • Before operation, a high fever in children should
    be reduced if possible.
  • In adults, antibiotic options include
  • cefoxitin 80 to 160 mg/kg/day divided qid
  • amikacin 15 mg/kg/day divided tid clindamycin
    20 to 40 mg/kg/day divided qid or tid
  • the choices are the same in children

67
Perforated appendix
  • NG tube
  • urine output
  • adequate IV fluid and electrolyte replacement.
  • If an abscess or an inflammatory mass has formed,
    operation may be limited to drainage of the
    abscess
  • whenever possible, the appendix should be removed
    as well.

68
Perforated colon
  • caused by obstruction, diverticulitis,
    inflammatory disease, and toxic megacolon.
  • Sometimes perforation occurs spontaneously.
  • In the presence of colonic obstruction,
    perforation of the cecum can occur this
    catastrophe is imminent if the cecum is gt 13 cm
    in diameter

69
Perforated colon
  • Perforated diverticulitis of the sigmoid or right
    colon is the most common cause of peritonitis
    from a perforated colon.
  • Patients receiving prednisone are apt to have
    such perforations
  • immunosuppressive drugs (eg, cytotoxins) also
    increase the danger of perforation.
  • Other diseases that lead to perforation are
    ulcerative colitis, Crohn's disease, and any
    cause of toxic megacolon.
  • Colonic resection usually always indicated

70
Necrotizing Enterocolitis
  • An acquired disease, primarily of preterm (75)
    or sick newborns
  • characterized by mucosal or even deeper
    intestinal necrosis, most commonly in the
    terminal ileum, with the colon and the proximal
    small bowel involved less frequently.

71
NEC
  • stools occult blood
  • Early x-rays may be nonspecific and reveal only
    ileus.
  • a fixed, dilated bowel loop that does not change
    on repeated x-rays indicates NEC.
  • X-ray signs diagnostic of NEC are pneumatosis
    intestinalis and portal venous gas
  • Pneumoperitoneum indicates bowel perforation and
    an urgent need for surgery

72
Operative intervention for NEC
  • needed for 1/3 newborns
  • Absolute indications
  • intestinal perforation (pneumoperitoneum),
  • signs of peritonitis
  • aspiration of purulent material from the
    peritoneal cavity
  • clinical and laboratory condition worsens despite
    nonoperative support

73
Vascular lesions of the intestine or colon
  • lead to gangrene and peritonitis.
  • thrombotic occlusion of the SMA
  • embolization to the SMA
  • Hallmark the severity of the pain far exceeds
    the physical findings early in the process.
  • The WBC count may rise to 20,000 or 30,000/µL

74
Vascular lesions
  • Mesenteric venous thrombosis is associated with
    polycythemia vera, severe liver disease, and
    contraceptive use, but it may be idiopathic.
  • Arteriography will identify the venous nature of
    the process.

75
Vascular lesions
  • Mesenteric venous thrombosis associated with
  • polycythemia vera
  • severe liver disease
  • contraceptive use
  • idiopathic.
  • Arteriography will identify the venous nature of
    the process

76
Perforated gallbladder or biliary tree
  • Acute cholecystitis can lead to perforation of
    the gallbladder
  • The most common cause of bile peritonitis arising
    from the bile ducts is iatrogenic damage during
    cholecystectomy.

77
Primary acute peritonitis
  • generalized abdominal pain, fever, and ileus with
    vomiting and either diarrhea or constipation.
  • Pneumococcal peritonitis, although uncommon, is
    the most frequent cause of this condition, which
    occurs chiefly in young girls (vaginal)
  • 25 of cases occur in males? from septicemia
  • Other organisms streptococci, staphylococci

78
Primary acute peritonitis
  • Most cases are associated with septicemia
  • If the disease is suspected? abdominal tap
  • If pneumococci, staphylococci, or streptococci
    are found? iv antibiotic at once
  • If no fluid can be found or if the smear shows a
    mixture of gram-positive cocci and gram-negative
    bacilli? a laparotomy is necessary

79
Pancreatitis
  • Cause an exudate that at first is
    retro-peritoneal but soon involves the peritoneal
    cavity
  • Chemical peritonitis
  • Initially with a high level of amylase in the
    exudate
  • Later, contamination with organisms from the GI
    tract may occur.

80
Pancreatitis
  • If the diagnosis seems certain and trauma was not
    a factor, laparotomy usually is avoided and
    reserved for the complications of pancreatic
    necrosis, abscess, or pseudocyst
  • However, failure to improve may be an indication
    for earlier operation

81
Toxic megacolon
  • Alternative names toxic dilation of the colon
  • Definition
  • Toxic megacolon exists when the diameter of the
    T-colon exceeds 6 cm
  • The severely ill patient has a fever to 40 C
    (104 F), leukocytosis, abdominal pain, and
    rebound tenderness.

82
Causes, incidence
  • extensive damage to the lining of the lower
    portion of colon and inflammation of underlying
    cell layers
  • may be associated with ulcerative colitis,
    Crohns disease, amebiasis, pseudomembranous
    colitis, typhoid, and bacterial dysentery
  • In children, severe Hirschsprungs disease can be
    a common cause

83
Risk factors
  • Contributing factors may be use of lexatives or
    cathartics, opiates used to treat diarrhea,
    anticholinergic medications, and low serum K
    levels. The incidence is 1 out of 100,000 people

84
Prevention
  • Minimize use of laxatives, opiates

85
Treatment
  • decompress the bowel and pass an intestinal tube
  • Fluid and electrolyte replacement
  • If decompression is not achieved or the patient
    does not improve in 24 hours ? colectomy is
    indicated
  • Use of corticosteroids
  • Antibiotics are indicated to prevent sepsis

86
Expectations (prognosis)
  • The death rate is high, usually 20 to 30.
  • With prompt, effective treatment, the mortality
    rate can be held at lt 4 but may be gt 40 if
    perforation occurs
  • A colectomy is usually required.

87
bacterial causes of inflammatory diarrhea include
  • Campylobacter
  • Shigella
  • Enteroinvasive E coli
  • E coli 0157 H7
  • Salmonella
  • Yersinia enterocolitica
  • Aeromonas species
  • Vibrio parahaemolyticus

88
Shigella
  • the most common cause of bacillary dysentery
    worldwide

89
incidence
  • The incidence in developing countries may be 20
    times greater than in developed countries.
  • it is estimated that 30 of these infections are
    caused by S dysenteriae.
  • Case-fatality rates for S dysenteriae infections
    may approach 30.

90
  • Patients with malnutrition are at increased risk
    of having complicated course.
  • Shigella infection in malnourished children often
    causes a vicious cycle of further impaired
    nutrition, recurrent infection, and further
    growth retardation

91
Mortality/Morbidity
  • Whereas mortality caused by shigellosis is rare
    in developed countries, S dysenteriae infection
    is associated with significant morbidity and
    mortality rates in the developing world.

92
  • Dehydration is the most common complication of
    shigellosis

93
Campylobacter
94
  • In developing countries, C jejuni is especially
    common during the first 5 years of life. (
    isolated from stools)
  • Isolation rates in children who are asymptomatic
    or children with diarrhea range from 8-45
  • Annual incidence 2.1 episodes of
    Campylo-bacter-associated diarrhea per child

95
Mortality /Morbidity
  • The vast majority of patients recover fully after
    C jejuni infection within 5 days (range 2-10
    d)(spontaneously or after antimicrobial therapy)
  • Symptomatic Campylobacter infection-associated
    mortality rate in the US is estimated as 24 per
    10,000 culture-confirmed cases or 200 deaths per
    year.

96
  • Infection with C fetus is of concern in patients
    who are immunocompromised, women who are
    pregnant, and neonates.
  • Previously healthy patients usually recover
    without complications.
Write a Comment
User Comments (0)
About PowerShow.com