case presentation on iatrogenic perforation
DESCRIPTION
Case presentation on Iatrogenic perforationTRANSCRIPT
CASE PRESENTATION
Dr. Rushdan Zakariah
Intern Doctor
Surgery Department,
Purple Unit
Mr. Mosharaf Hossain, 26 years of age hailing from Norshingdi admitted here on 2nd October 2010 with the complaints of –
A. Pain in the whole abdomen - 4 hrs
B. Abdominal Distension - 4 hrs
C. Shortness of breath - 2 hrs
According to the statement given by the patient, he was reasonably well four hours back. On 2nd October morning he came to this hospital for colonoscopy as he was advised from medicine OPD for his bleeding per rectum since last 2 months.
Then after attending colonoscopy he complains of severe abdominal pain which he could not tolerate and pain aggravates with movement. He had also abdominal distension for the same duration and difficulty in breathing for last two hours.
H/O Past Illness: No H/O HTN,DM, Bronchial Asthma or such
Drug History: Nothing Contributory
Allergy History: Same as above
Personal History: Same as above
Immunization History: Immunized as per EPI Schedule
General Examination:Appearance: Toxic Body built: AverageCo operation: Co operativeDecubitus: SupineNutrition: GoodAnemia: AbsentJaundice: AbsentCyanosis: AbsentClubbing: AbsentKoilonychia: AbsentLeuchonychia: AbsentEdema: AbsentDehydration: AbsentThyroid Glands: Not
palpableLymph Nodes: Not enlargedNeck Veins: Not engorged
Swellings: AbsentBP: 130/80 mm HgPulse: 120 beats / minTemperature: 99º FRespiratory rate: 28 breaths / min
Systemic Examination:
Alimentary System: Per Abdominal Exam: Inspection: Restriction of movement with
respiration, Umbilicus everted, flanks were full and concave
Hernial orifices: Intact Palpation: Board like rigidity Percussion: Obliteration of liver dullness Auscultation: Sluggish bowel sound
Systemic Examination:
Respiratory System: Inspection: Use of accessory muscles
Respiratory rate: 28 breaths / min Palpation: Normal Percussion: Resonant Auscultation: Vesicular breath sound with
no added sound
Systemic Examination:Cardiovascular System: Inspection:
Visible pulsation & venous
engorgement were absent Palpation:
Apex beat: In normal position
Thrill: Absent
Left Parasternal Heave: Absent
Palpable P 2: Absent Auscultation: 1st & 2nd heart sound
audible
So, What is the diagnosis ????
Investigations: CBC with ESR - Hb%: 15.4 gm/dl ESR: 10 mm Total Count of WBC: 7,600 / mm3
Platelet Count: 2,77,000 / mm3
S. Electrolytes - Na: 138.0 mmol / L K: 3.8 mmol / L Cl: 100.0 mmol / L S. Creatinine – 1.2 mg / dl Blood grouping & Rh typing – ‘O’ +ve Urine R/E & C/S – Normal HBSAg - Negative
CXR – P/A view
X ray of abdomen E/P
USG of whole abdomen
USG of whole abdomen
Final Diagnosis:
Iatrogenic Perforation
Immediate Management :
Patient was kept NPO I/V Fluid was given 3000 ccNG Suction was done 4 hourlyBroad spectrum antibiotics were started AnalgesicAnti ulcerantAnti emeticTransfusion of 2 units of whole fresh bloodContinuous catheterization & strictly
maintenance of I/O chart
Surgical Management :
Emergency OT was arranged at 11:45 pm. Laparatomy was done under G/A on 2nd Oct, 2010. Midline incision was given. Moderate amount of fluid collection was found & it was evacuated. Perforation noted at sigmoid colon. There were 3 serosal tears. There were no tumor or ulcer, lymph nodes were not enlarged. After mobilizing, resection anastomosis was done with 3-0 vicryl. Serosal tears were repaired with same suture. Proper peritoneal toileting was done. 2 drain tubes were placed on each side of incision. Linea alba was closed with 1-0 prolene. Wound was kept open for delayed primary suture.
Per Operative Photograph:
Post Operative Management :
NPO for 3 daysNG Suction 4 hourly I/V Fluid – 3000 ccBroad spectrum antibiotics – Ceftriaxon,
Metronidazole & AmikacinAnalgesicAnti ulcerant Anti emetic
Follow up :1st POD: BP, Pulse, Respiratory Rate – Good Temp – 100 degree F Abdomen – Soft Chest - Clear Bandage – Dry Drain – 200 cc Bowel sound – Absent 2nd POD: Temp – 102 degree F Suppository Paracetamol 1 stick P/R given Drain – 120 cc3rd POD: Vitals - Good Serum K – 2.9 mmol / l Inj. KCl (2 amp) was given in normal saline Dressing was done
4th POD: Diet – Sips of water Drain – 70 cc Temp – 99 degree F5th POD: Diet – Clear liquid followed by soft rice Drain – 40 cc Patient developed diarrhoea
Ranitidine was given instead of Omeprazole6th POD: Drain tubes and catheter were removed Diet – Regular Dressing was done7th,8th and 9th POD: Improvement of diarrhoea10th POD: Delayed primary suture was given & 1 drain was kept in situ11th POD: Patient is improving & doing good
12th POD: Dressing was done, drain tube was removed & patient was discharged
Our next Plan: The patient was advised to visit Surgery OPD after
7 days to remove stitch, wound will be checked then for any discharge or any kind of abnormality. Also the patient will be asked for any complaints he feels after leaving hospital.
Thank you for your patience
hearing and time.