Cases reported "Intestinal Perforation"

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1/106. Multiple intestinal ulcerations and perforations secondary to methicillin-resistant staphylococcus aureus enteritis in infants.

    PURPOSE: The aim of this study was to define a distinctive clinical entity of multiple intestinal ulcerations and perforations in infants. methods: Two infants underwent abdominal exploration for surgical abdomen and were noted to have multiple intestinal ulcerations and perforations. A peculiar and unique surgical finding, numerous transverse linear ulcerations scattered along the entire small intestine, prompted us to search for similar instances. Five similar cases were additionally identified by members of the Korean association of Pediatric Surgeons. The clinical courses, the surgical findings, and the results of bacterial cultures were reviewed. As well, the tissues of resected intestines were examined histopathologically. RESULTS: The characteristics of this entity are as follows. (1) It usually occurs in infants who have been treated with broad-spectrum antibiotics. (2) Despite broad-spectrum antibiotic treatment, diarrhea and abdominal distension developed progressively and deteriorated. (3) Histological evaluation showed mucosal ulcers with neutrophil infiltration, submucosal microabscesses, and colonies of gram-positive cocci. (4) methicillin-resistant staphylococcus aureus (MRSA) was the predominant organism cultured from the body fluid. (5) Only two cases, the completely resected one and the one immediately treated postoperatively with vancomycin, survived. CONCLUSIONS: This entity is caused by multiple intestinal ulcerations and perforations secondary to MRSA enteritis in infants. It has a high mortality rate because of its difficult diagnosis. However, early recognition of this entity can lead to successful treatment.
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2/106. Poor outcome of gastrointestinal perforations associated with childhood abdominal non-Hodgkin's lymphoma.

    BACKGROUND/PURPOSE:With modern chemotherapeutic protocols and advances in medical care, the outcome of intraabdominal non-Hodgkin's lymphoma (NHL) in children can be excellent for limited disease. Advanced disease, however, is associated with increased tumor aggression and requires more rigorous adjuvant therapy. Hence, complications early in the course of the disease process or its management often lead to a poor outcome. Perforation of the gastrointestinal tract, either iatrogenic, tumor related or chemotherapeutically induced is one such complication and may result significant morbidity and mortality. methods: The authors reviewed their experience with this disease, and present two cases of children with abdominal NHL, which poignantly demonstrate these points. Results and a review of the literature are then discussed. RESULTS: Fifteen cases of abdominal NHL were examined with an overall mortality rate of 40%. This increased to 100% in the presence of perforation. In two cases, inadvertent entry into the bowel occurred at the time of laparotomy for tumor biopsy. In the first case, intestinal wall was included in the biopsy specimen; in the second, laparotomy unmasked an already sealed-off perforation secondary to tumor invasion. sepsis ensued in both cases. In the first, this resulted in repeated delays in chemotherapy, and the child succumbed to the disease. In the second, chemotherapy was continued, and although the small bowel leak was controlled, the initial insult hampered marrow recovery and host defenses, resulting in fatal sepsis. CONCLUSIONS: These data and other reported cases in the literature indicate that intestinal perforation associated with abdominal lymphomas in children portends an extremely poor prognosis. All attempts to avoid this complication should be made, including avoiding direct tumor biopsy whenever possible.
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ranking = 2
keywords = mortality
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3/106. schistosoma japonicum infection presenting with colon perforation: case report.

    colon perforation can be caused by a variety of entities, including iatrogenic trauma, tumors, ischemia, inflammatory bowel disease, and steroid use. Parasitic infection rarely leads to colon perforation. Secondary peritonitis results from mixed microorganism infection, including enterococci, enteric bacilli, and anaerobes. A combination of an optimal antibiotic regimen and surgical intervention is of paramount importance. Nevertheless, intra-abdominal infections usually have a high mortality rate. schistosomiasis occurs worldwide. S. japonicum infection is endemic in asia. The most common complications of gastrointestinal schistosomiasis are periportal fibrosis, intestinal polyposis, and bowel stricture. Rarely, schistosomiasis results in colon perforation. The diagnosis of schistosome infections is based on ova in stool or tissue specimens, and/or immunologic diagnostic tests. The most effective anti-schistosomiasis agent is praziquantel. Herein, we describe an unusual case of colon perforation associated with schistosoma japonicum infection, which resulted in severe peritonitis and led to the patient's death.
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4/106. intestinal perforation secondary to salmonella typhi: case report and review of the literature.

    The case of a young woman presenting with fever, abdominal distention, and diarrhea is presented. While hospitalized, she developed peritonitis, and a laparotomy was performed emergently. Intraoperative and pathologic examinations are highly suggestive of salmonella typhi as an etiology for her symptoms and eventual perforation. Salmonella enteritis can be a difficult diagnosis to make, but in most cases it is a self-limited disease process. In a minority of cases, multidrug antibiotic therapy may be required secondary to an increasing prevalence of resistant strains. patients who perforate require prompt operation to limit morbidity and mortality. Outcome is significantly improved in those patients by directed resection of the affected segment of bowel and by aggressive perioperative care.
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5/106. Perforated jejunal diverticulitis: personal experience and diagnostic with therapeutical considerations.

    A case of perforated jejunal diverticulitis in a 87-year-old man is described and the literature is reviewed. Jejunal diverticulosis (JD) is estimated to occur in 0.02% to 1.3% of the adult population and is found most often in the elderly. The acute diverticulitis with perforation has been reported as high as 2.3% among patients with JD and is associated with high mortality. Clinical presentation mimic other more common acute intraperitoneal inflammatory conditions. Enteroclysis and abdominal CT are the most specific diagnostic tests. The common treatment is surgical resection of the involved segment. Laparoscopic resection and medical and medical/radiological approaches have also been proposed. Diagnostic and therapeutical aspects of this pathology are discussed.
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6/106. Colonic perforation associated with slow-release diclofenac sodium.

    upper gastrointestinal tract complications due to non-steroidal anti-inflammatory drugs are well recognised. However, adverse effects on large intestinal mucosa are less common and less well recognised, even though they carry a significant morbidity and mortality. Here we report a case of colonic perforation in a healthy woman without any underlying colonic pathology associated with ingestion of slow release diclofenac sodium.
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7/106. Successful use of the "patch, drain, and wait" laparotomy approach to perforated necrotizing enterocolitis: is hypoxia-triggered "good angiogenesis" involved?

    The traditional and most frequently employed surgical approach to perforated necrotizing enterocolitis (NEC), laparotomy and bowel resection with enterostomy creation, has been associated with an unacceptably high mortality and major morbidity (sepsis, short-gut syndrome, strictures, long-term total parenteral nutrition (TPN), prolonged and costly hospitalizations with multiple operations, the inevitable open-and-close procedure for "hopeless" extensive gut ischemia in approximately 10% of laparotomy cases, etc.). The use of the laparotomy "patch, drain, and wait" (PD&W) approach to this serious of NEC complication has provided a simple, direct, and effective means of dealing with this problem. The basic principle is to resect no gut and do no enterostomies. The details are presented here as well as the multiple types of "patching" and the importance of use of extensive direct-vision draining with bilateral small Penrose drains from the undersurfaces of both diaphragms into the pelvis with exit sites in both lower quadrants. Proper and effective patching and draining cannot be done blindly,but requires direct vision (laparotomy or laparoscopy). The critical components and timing of the "waiting" are emphasized, including the vital importance of strict avoidance of early post-drainage laparotomy in the 7- to 14-day post-drainage period (whether the drainage is percutaneous, laparotomy PD&W, or laparoscopy PD&W) due to the early, life-threatening-ending hypervascularity that occurs at this time and if left unmolested will function beneficially as life- and gut-saving "good angiogenesis". The bilateral Penrose drains capture fecal fistulas and function quite well as de-facto enterostomies as the peritoneal cavity is rapidly obliterated by adhesions and massive, florid hypervascularity/gut hypoxia triggered "good angiogenesis" (no peritoneal cavity, no peritonitis). Broad-spectrum triple antibiotics and the routine use of TPN contribute to favorable results. The lessons/experiments of nature encountered in newborns with midgut atresia(s) and remarkable levels of gut survival, in the occasional case with only meconium peritonitis and no obstruction ("auto-anastomosis") are pertinent here as the TPN of PD&W is provided in atresia(s) by the maternal-placental circulation and the sterile peritoneal cavity of atresia(s) is simulated by the combination of antibiotics and peritoneal-cavity obliteration. life- and gut-saving "good angiogenesis" is common to both situations. A 15-year personal experience with the PD&W laparotomy approach to perforated NEC in 23 cases is reported here with no mortality in the initial 60 postoperative days, no major morbidity, and no second operation required in 70% (spontaneous "auto-anastomosis") of cases. All infants with extensive gut ischemia/necrosis (NEC totalis) who would otherwise be classified as "hopeless" and managed by open-and-close only were managed in this experience successfully by PD&W with preservation of both life and an adequate amount of gut, although a second operation was required in these cases to re-establish intestinal continuity. A particularly striking observation was the rapid transition of these infants from profound illness to near-normalcy in a matter of hours after the initiation of PD&W--much like the rapid clinical changes accompanying the lancing of a boil or an abscess. An involvement of hypoxia-induced "good angiogenesis" with marked hypervascularity and involving molecules, genes, and receptors of the vascular endothelial growth factor family of hypoxia-induced angiogenesis molecules is speculated upon, and clinical studies to document these speculations are suggested as well as studies evaluating the potential of laparoscopic PD&W. The usefulness of Argyle chest-tube "venting" and "stenting" by trans-anal passage above colonic "patched" areas as seen in 2 cases is worthy of further study and use.
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ranking = 2
keywords = mortality
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8/106. Use of CT scan in the diagnosis of pediatric acute appendicitis.

    BACKGROUND: The efficacy of CT scan in the diagnosis of pediatric appendicitis has hot been established. methods: Every patient under the age of 18 who was diagnosed and treated for acute appendicitis in the 1 year period from March 1998-March 1999 at Lakeland Regional Medical Center were included. The presentation, laboratory evaluation, imaging evaluation, hospital course, and pathologic evaluation were reviewed. Selected imaging studies were reviewed by an independent radiologist. RESULTS: Forty-six patients were treated for appendicitis; 17 of them received CT scans (37%). The CT scans predicted appendicitis in 9 of 17 cases (sensitivity = 53%). False-negative studies resulted in some morbidity but no mortality. The radiology review indicated that three cases clearly did not demonstrate appendicitis. The other false-negative studies were secondary to either technical or professional factors. CONCLUSION: The efficacy of CT imaging in the diagnosis of acute appendicitis in children has still not been demonstrated. This limited series indicates that if CT scanning is to be used in pediatric patients, more attention to technical and professional factors may be required. Some of these factors, particularly the ingestion of oral contrast, are particularly problematic in small children and may limit the effectiveness of this modality.
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ranking = 1
keywords = mortality
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9/106. Small bowel perforation: an unusual presentation for child abuse.

    Hollow viscus perforation due to inflicted blunt abdominal injury is uncommon. diagnosis is frequently delayed because of inaccurate or absent history, nonspecific or delayed physical findings or both, and laboratory tests with low sensitivity. Computed tomographic scanning of the abdomen is the best diagnostic test available. A high index of suspicion is essential to diagnose visceral perforation early, as significant morbidity and mortality results from diagnostic delay.
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10/106. Colonic perforation in unsuspected amebic colitis.

    Unsuspected amebic colitis presenting as inflammatory bowel disease, as in our patient, has been previously reported (4, 7, 8). Misdiagnosis, delay in antibiotic treatment, and institution of immunosuppression were the result of failure to identify the parasite in stool specimens and have resulted in suffering, morbidity, mortality, and surgery. In all previously reported cases, routine stool studies failed to identify E. histolytica (4, 7, 8). The correct diagnosis was only established after reviewing the surgical specimen or biopsies obtained endoscopically. Because the erroneous diagnosis of inflammatory bowel disease can lead to disastrous complications, it is imperative to exclude amebic colitis prior to undertaking steroid therapy, especially in patients with a prior history of travel to or residence in areas with endemic E. histolytica (17). We recommend obtaining at least three stool specimens for microscopic examination, as well as testing for serum amebic antibody. patients should submit fresh stool specimens directly to the laboratory to allow for prompt diagnostic evaluation. Such an approach might lead to the improved diagnosis of amebiasis.
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