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.