3 mins read
Look beyond the obvious !
This case was Contributed by :
Dr Faisal Masoodi
MBBS, MS (surgery) DNB GI Surgery
Consultant Hepato biliary Surgery
Govt.Medical College Handwara KASHMIR
email: faizalmasoodi@gmail.com
Clinical scenario:
A 23 year old male presented to us with history of trauma sustained in a road traffic accident. Patient complained of pain in his abdomen aggravated by any movement. There was no history suggestive of traumatic brain injury or intra thoracic trauma.
Examination:
Patient was concious, oriented and haemodynamically stable blood pressure 120/ 80 mm Hg. There were few abrasions on the right flank and right lateral chest wall. Abdominal examination revealed a generalized rigidity and tenderness with rebound positive. He had hemoglobin of 14 gm/dl. A preliminary diagnosis of perforation peritonitis was made and further confirmed by evidence of pneumoperitoneum and free intraperitoneal fluid on abdominal C.T.
Hospital Course:
Examination:
Patient was concious, oriented and haemodynamically stable blood pressure 120/ 80 mm Hg. There were few abrasions on the right flank and right lateral chest wall. Abdominal examination revealed a generalized rigidity and tenderness with rebound positive. He had hemoglobin of 14 gm/dl. A preliminary diagnosis of perforation peritonitis was made and further confirmed by evidence of pneumoperitoneum and free intraperitoneal fluid on abdominal C.T.
Hospital Course:
Patient was taken for a laparotomy and multiple jejunal perforations were identified and repaired primarily. Patient was started on orals on 3rd post operative day and drains were removed on 5th post operative day when they were showing a minimal drainage of serous fluid (< 15 ml).
Two days after removal of drains patient developed fever. Ultrasound showed no intra abdominal collection however a chest radiograph picked up a consolidation in the right lower lobe with minimal effusion. Patients total leucocyte counts paradoxically dropped in the range of 2000-2500/cumm. Treatment was started for post operative pneumonia with neutropenia in collaboration with physicians. After recieving antibiotics for a week the patient continued to be febrile and a battery of investigations did not yield any conclusive results.
Ultimately our repeated clinical examination of the patient provided us the lead after a week when we detected a tenderness in the right renal angle.A repeat C.T. of abdomen ( Fig 1) was ordered which showed a right perinephric fluid collection containing free gas as well. Shown as extravasated contrast medium ( white shadow showing contrast on right paravetevral area suggestive of duodenal fistula ) A loculated gas containing collection was also found in the right hemithorax C.T. with oral contrast ( fig 1 )showed a leakage of dye into the peri-nephric collection, tracking into the right pleural cavity. The patient was re-operated 10 days after the first surgery with the diagnosis of duodenal perforation. A lot of pus was drained from the retro peritoneum and drains were placed in abdomen as well as chest. The condition of tissues precluded any attempts at repair of the perforation.
Two days after removal of drains patient developed fever. Ultrasound showed no intra abdominal collection however a chest radiograph picked up a consolidation in the right lower lobe with minimal effusion. Patients total leucocyte counts paradoxically dropped in the range of 2000-2500/cumm. Treatment was started for post operative pneumonia with neutropenia in collaboration with physicians. After recieving antibiotics for a week the patient continued to be febrile and a battery of investigations did not yield any conclusive results.
Ultimately our repeated clinical examination of the patient provided us the lead after a week when we detected a tenderness in the right renal angle.A repeat C.T. of abdomen ( Fig 1) was ordered which showed a right perinephric fluid collection containing free gas as well. Shown as extravasated contrast medium ( white shadow showing contrast on right paravetevral area suggestive of duodenal fistula ) A loculated gas containing collection was also found in the right hemithorax C.T. with oral contrast ( fig 1 )showed a leakage of dye into the peri-nephric collection, tracking into the right pleural cavity. The patient was re-operated 10 days after the first surgery with the diagnosis of duodenal perforation. A lot of pus was drained from the retro peritoneum and drains were placed in abdomen as well as chest. The condition of tissues precluded any attempts at repair of the perforation.
The patient was managed as a duodenal fustula and leakage of bile decreased after 15 days. Gradually orals were started and patient was discharged after 1 month .
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| Fig 1 CT scan Abdomen showing leakage of dye in peri nephric area |
Teaching message :
The need to look beyond the obvious, in our case the jejunal perforations during surgery and right lower lobe consolidation post operatively, cannot be over emphasized. As also the importance of a meticulous clinical examination which guided us to appropriate management
Further reading :-
Click the link Blunt Abdominal Trauma
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