1/18. Vasculitic small bowel perforation masquerading as spontaneous bacterial peritonitis in a patient with decompensated liver disease.We report on a young patient with decompensated alcohol-induced liver disease (child-Pugh score C) who presented with clinical, biochemical and radiological evidence suggestive of spontaneous bacterial peritonitis. She was however subsequently found to have multiple small bowel perforations, which were diagnosed only at laparotomy. The histology of the bowel showed evidence of vasculitis. This case illustrates two important points. Firstly, even if a patient has all the prerequisites to develop spontaneous bacterial peritonitis, a secondary cause of peritonitis (eg. bowel perforation or intra-abdominal abscess) must always be considered as a differential diagnosis and a repeat ascitic tap is mandatory after 48 h of antibiotic therapy to confirm a decrease in the white cell count. Secondly, it shows the rare co-existence of alcoholic liver disease and vasculitis.- - - - - - - - - - ranking = 1keywords = white (Clic here for more details about this article) |
2/18. Intensive plasma exchange for severe autoimmune hemolytic anemia in a four-month-old infant.We report the smallest infant (7.5 kg) to receive intensive plasma exchange (52 PEs) therapy as treatment of autoimmune hemolytic anemia (AIHA). PE temporarily reduces circulating autoantibody levels and can be an effective adjunctive therapy with corticosteroids and cytotoxic drugs or other immuno-suppressants. Although his clinical course was prolonged and complicated by cytomegalovirus infection with spontaneous perforation of his colon, his recovery was complete. He has remained healthy for more than 2 years. Because of his small size, calcium gluconate was added to replacement fluids and calcium levels closely monitored. The apheresis machine and tubing were routinely primed with red blood cells and FFP substituted for 5% human albumin during the second half of all procedures to maintain adequate levels of procoagulant. Our experience suggests that intensive PE is helpful in controlling severe AIHA and should be considered even for very small patients.- - - - - - - - - - ranking = 6.4209057308337keywords = blood cell (Clic here for more details about this article) |
3/18. Retroperitoneal perforation of the appendix presenting as right thigh abscess.A case of retroperitoneal perforation of the appendix presenting with a thigh abscess is described. The patient presented with pyrexia (38 degrees C) and abdominal and right thigh pain. There was tenderness in the right loin. His white blood cell count was 22 x 10(9)/L. An intravenous urogram revealed tapering of the right ureter at the L2/L3 level and suggested an infected obstructive uropathy. The patient failed to respond to drainage and antibiotics, so we performed a computed tomography scan, which showed a retroperitoneal abscess extending to the gluteal region and thigh, with signs of small bowel obstruction. This precipitated surgery. The route of extension of infection was through the sacrosciatic notch, which is considered to be a rare way of spread. The patient made a slow but eventual recovery. The overall mortality of this condition is high, but early recognition of an abdominal source of sepsis with appropriate treatment can improve survival.- - - - - - - - - - ranking = 7.4209057308337keywords = blood cell, white (Clic here for more details about this article) |
4/18. Retroperitoneal perforation of a duodenal diverticulum with colonic necrosis -- report of a case.Primary duodenal diverticula are usually asymptomatic. About 115 perforations have been reported, but none with right colon necrosis. We report a 45-year-old woman, with a five days history of high fever along with epigastric and periumbilical pain. physical examination revealed right upper and lower quadrant tenderness with peritoneal signs. White blood cell count was 11 500/mm (3) while biochemical and hepatic biology tests were normal. Abdominal radiographs showed no pathologic findings. Ultrasound disclosed fluid in the lower pelvis. Computerized tomography revealed fluid collection in the right hepatorenal space. Intraoperative findings included purulent fluid in the lower pelvis, segmental necrotic changes of the right colon, and a perforated diverticulum on the antimesenteric border of the third part of the duodenum. Surgery consisted of right hemicolectomy and ileo-transverse anastomosis, diverticulectomy, and decompressive lateral duodenostomy at the second duodenal portion. The patient had an uneventful postoperative course. A contrast study from the duodenostomy tube on the 6 (th) postoperative day showed no leakage or obstruction. duodenostomy tube was removed on the 14 (th) postoperative day. histology confirmed the diagnosis of a primary duodenal diverticulum.- - - - - - - - - - ranking = 6.4209057308337keywords = blood cell (Clic here for more details about this article) |
5/18. Acute colonic diverticular perforation presenting as left ear pain and facial swelling due to cervical subcutaneous emphysema in a patient administered corticosteroids.A 56-yr-old white female administered corticosteroids presented with left ear pain and facial swelling due to cervical subcutaneous emphysema from a diverticular perforation of the sigmoid colon. This case demonstrates that localized signs of a bowel perforation may be absent in patients administered corticosteroids, that these patients may present with unusual, remote findings, and that bowel perforation can produce cervical subcutaneous emphysema.- - - - - - - - - - ranking = 1keywords = white (Clic here for more details about this article) |
6/18. Successful treatment of multiple small-bowel perforations caused by cytomegalovirus in a patient with malignant lymphoma: report of a case.We report the successful management of multiple small-bowel perforations caused by cytomegalovirus (CMV) infection in a 60-year-old man, 1 day after CHOP (cyclophosphamide/doxorubicin/vincristine/prednisone) therapy induction for malignant lymphoma. Emergency laparotomy was performed for perforative peritonitis, but we did not resect the lesions at this time. Instead, we exteriorized the small bowel and then irrigated the peritoneal cavity and intestinal tract. His white blood cell count was low, at 200 cells/microl, so this therapy was continued until it recovered. The intestine was highly edematous, but it improved after irrigation with peritoneal dialysis solution. In the second-stage procedure, we resected the small bowel with the perforations, and constructed a jejunostomy and colostomy, then closed the abdominal cavity. Although the patient needed central venous hyperalimentation, he had a favorable postoperative course and started treatment again for the malignant lymphoma.- - - - - - - - - - ranking = 7.4209057308337keywords = blood cell, white (Clic here for more details about this article) |
7/18. Multiple small bowel perforations in leukemia secondary to Epstein-Barr virus lymphoma with survival: a case report.This is the case report of a 4-year-old white boy who was diagnosed as having acute lymphoblastic leukemia (ALL) in November 1985. While in remission and on maintenance chemotherapy, he developed a primary Epstein-Barr virus (EBV) respiratory infection in October 1986. On October 27, 1986 a plain abdominal radiograph taken for abdominal distention showed free air. At celiotomy, multiple nodules were noted to stud the small bowel. Central necrosis of these nodules with perforations were present in the distal small bowel. Resections and end-to-end anastomoses were performed. Three days later the patient again had a similar acute abdominal episode. At reexploration, similar lesions in the liver, kidney, duodenum, proximal jejunum, and colon were found. liver biopsy as well as intestinal resections and end-to-end anastomoses were performed, along with a loop ileostomy. Polymorphic B-cell lymphoma positive for EBV was found in the specimens. After cessation of chemotherapy and institution of abdominal radiotherapy, the hepatic and renal lesions were seen to resolve on computed tomography scan. The patient's course was complicated by the development of cervical and mediastinal abscesses that were drained, and E coli sepsis accompanied by chronic diarrhea requiring intravenous hyperalimentation. By January 1988, he appeared to be recovering. His ileostomy was closed in March 1988. Despite cessation of chemotherapy since October 1986, the patient is now well and in complete remission.- - - - - - - - - - ranking = 1keywords = white (Clic here for more details about this article) |
8/18. Perforation of the colon in a 15-year-old girl with ehlers-danlos syndrome type IV.A 15-year-old girl presented with severe fecal peritonitis due to a large spontaneous colonic perforation. The sigmoid colon was the site of a cluster of white serosal lesions with omental adhesions, of an appearance identical to that of the edges of the perforation. Her father had died at 30 years of age of spontaneous rupture of an iliac artery aneurysm, preceded by rupture of a splenic artery aneurysm and a spontaneous carotid-cavernous fistula. The clinical diagnosis of ehlers-danlos syndrome type IV was made, and confirmed by demonstrating that the patient's cultured fibroblasts are not producing or secreting type III collagen. Spontaneous perforation of the colon is a well-described complication of this syndrome, with a high incidence of recurrence. We recommend total abdominal colectomy to minimize the latter possibility.- - - - - - - - - - ranking = 1keywords = white (Clic here for more details about this article) |
9/18. Cyclic neutropenia with colonic perforation and nonhealing colocutaneous fistula.Cyclic neutropenia is an hereditary disorder of white blood cells, characterized by profound neutropenic episodes approximately every three weeks. Septic complications are usually limited to cutaneous and oropharyngeal infections. A 4-year-old boy with known cyclic neutropenia was in shock with neutropenia, clostridial septicemia, and right lower quadrant peritonitis when he was admitted. At the time of laparotomy, inflammation of the cecum, with no gross perforation, was found; no resection or appendectomy was done. He subsequently developed a right lower quadrant abscess that was drained, resulting in a colocutaneous fistula. For the next 8 months his fistula persisted, with intermittent episodes of fever, increased fistula output, and abdominal pain during his neutropenic periods. Standard nonoperative approaches to healing the fistula failed (ie, elemental feeds, total parenteral nutrition, irrigations, antibiotics, and drains). Attempts to medically abolish his neutropenic episodes using lithium, gammaglobulin, and steroids also failed. Ultimately, he underwent an ileocecal resection with primary anastamosis; the operation was done immediately following a neutropenic episode, in order to allow adequate healing of his anastamosis before his next period of neutropenia. Postoperative course was satisfactory, and he remains well after 8 months follow-up. This case, and several similar previously reported cases, illustrate that cyclic neutropenia may present with serious surgical complications. They also underlines the important role that neutrophils play in the healing of enteric fistulae.- - - - - - - - - - ranking = 7.4209057308337keywords = blood cell, white (Clic here for more details about this article) |
10/18. Perforation of the terminal ileum with cytomegalovirus vasculitis and Kaposi's sarcoma in a patient with acquired immunodeficiency syndrome.This case report documents a perforation of the terminal ileum in a 40-year-old white male homosexual with the acquired immunodeficiency syndrome. The perforation occurred at a site that had severe cytomegalovirus infection and was in close proximity to multiple nodules of Kaposi's sarcoma. The ileum showed multiple deep ulcers with large numbers of cytomegalovirus inclusions and vasculitis with infected endothelial cells, small-vessel thrombosis, focal disruption, and hemorrhage. We review the evidence that cytomegalovirus infection--and not Kaposi's sarcoma--was responsible for this perforation and, in light of the new medical therapy for such infections, should be regarded as an important cause of gastrointestinal perforation in patients with the acquired immunodeficiency syndrome.- - - - - - - - - - ranking = 1keywords = white (Clic here for more details about this article) |
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