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Perforated Viscus


Presentation

  • The presentation of hypermagnesemia can be subtle, but should be considered in patients with gastrointestinal complications who present in shock.[ncbi.nlm.nih.gov]
  • We present herein a case of ruptured hepatic abscess mimicking perforated viscus. CASE REPORT: A 40-year-old man presented to the emergency room with fever and right upper quadrant abdominal pain. The fever had been on/off for a period of 1 month.[ncbi.nlm.nih.gov]
  • All patients presented late and most were elderly. The most common surgical procedure was diversion of the fecal stream proximal to the perforation. In our series 4 of 7 patients died in the immediate postoperative period.[ncbi.nlm.nih.gov]
  • Because patients with perforated hollow viscus may present in a moribund state and have ...[mhmedical.com]
  • The presentations of perforated viscous can be altered in patients with delayed presentation, immunocompromised state or who are elderly.[saem.org]
Fever
  • CASE REPORT: A 40-year-old man presented to the emergency room with fever and right upper quadrant abdominal pain. The fever had been on/off for a period of 1 month.[ncbi.nlm.nih.gov]
  • Furthermore, viscus perforation may be a consequence of inflammatory illnesses of the intestine such as typhoid fever. Perforation can be also associated with gastric or duodenal ulcers.[ic.steadyhealth.com]
  • Typhoid fever and certain infections and illnesses affecting the organs of the abdomen, can cause a perforated abdominal viscus.[buzzle.com]
  • They mostly include fever, low blood pressure, fast heart rate, abdominal pain, nausea, vomiting, and abdominal distention. Patients mostly are in severe pain with their abdomen feeling rigid or board-like when touched.[wisegeek.org]
  • Associated symptoms are nonspecific and may include fever, chills, nausea, vomiting, anorexia, change in bowel habits, weight loss (for contained perforation), syncope, dizziness, and dysuria.[mhmedical.com]
Severe Pain
  • pain and a rigid abdomen. this is a surgical emergency requiring immediate fluid resuscitation and transfer to theatre ASAP once diagnosis is made diagnosis in free perforations is usually supported by the finding of free gas under the diaphragm on an[ozemedicine.com]
  • Some of the commonly observed symptoms are severe pain in the abdomen, stiffness in abdomen upon touching, increased heart rate, lowering of the blood pressure, fever, a feeling of nausea, sometimes leading to vomiting and abdominal distention.[buzzle.com]
  • Patients mostly are in severe pain with their abdomen feeling rigid or board-like when touched. When prompt treatment for a perforated viscus is not given, patients often develop complications that can be life-threatening.[wisegeek.org]
  • Sudden onset of severe pain is likely to be either a vascular event e.g. ruptured AAA or ischaemic bowel, or perforated viscus e.g. ulcer, appendix or diverticulum. Pain from inflammation or infection is slowly progressive. b) Correct![ole.bris.ac.uk]
  • Symptoms develop suddenly, with severe pain followed shortly by signs of shock. Diagnosis is usually made by the presence of free air in the abdomen on imaging studies. Treatment is with fluid resuscitation, antibiotics, and surgery.[merckmanuals.com]
Gangrene
  • Bruce Schirmer, M.D. perf duodenal ulcer–38 sec outline–1:23 obese pt population–1:39 general operating principles–3:19 small bowel gangrene–4:57 massive enterolysis–6:05 IBS–6:47 C. diff–7:13 colonic neop Keyword(s): ABXs, bowel resection, C. diff, CD[sages.org]
Abdominal Pain
  • CASE REPORT: A 40-year-old man presented to the emergency room with fever and right upper quadrant abdominal pain. The fever had been on/off for a period of 1 month.[ncbi.nlm.nih.gov]
  • Abdominal pain is a leading reason for emergency department visits. 1 Acute abdominal pain accounts for 40% of emergency surgical hospital admissions, and a large proportion of these patients have perforated hollow viscus or impending gastrointestinal[mhmedical.com]
  • Recognition of pneumoperitoneum using bedside ultrasound in critically ill patients presenting with acute abdominal pain.[saem.org]
  • It is essential to include other life threatening causes of acute abdominal pain in the differential such as AAA/aortic dissection and mesenteric ischemia.[cdemcurriculum.com]
  • A person who believes that he or she has a perforated viscus or who is showing signs such as abdominal pain, vomiting, shock or has a stiff body, should see a doctor immediately.[reference.com]
Acute Abdomen
  • Early presentation of many of the causes of acute abdomen can be similar and difficult to distinguish.[saem.org]
  • Acute abdomen in the medical intensive care unit. Crit Care Med. 2002 Jun;30(6):1187-90. Jones R. Recognition of pneumoperitoneum using bedside ultrasound in critically ill patients presenting with acute abdominal pain.[cdemcurriculum.com]
  • Sonography And The Acute Abdomen; Practical Considerations. Am. J. Roentgenol.1997; 168:179-86. Edgar D. Staren, Guest Editor, Surgical clinics of North America 2004;84:IX-X. Braccini.Get al.[msjonline.org]
  • Gastrointestinal perforation and the acute abdomen. Med Clin N Am. 2008;92:599-625. Dhikav V, Singh S, Pande S, Chawla A, Anand KS. Non steroidal drug induced gastrointestinal toxicity:mechanisms and management. JIACM 2003;4:315-22. Kellog LC.[ijsurgery.com]
Severe Abdominal Pain
  • An 80-year-old woman with hypertension presents to the emergency department with the sudden onset of severe abdominal pain. The pain began abruptly 1 hour prior to her arrival, without any apparent antecedent events.[mhmedical.com]
  • The ill appearing patient presenting with acute severe abdominal pain and a characteristic abdominal exam should be considered to have a perforated viscus.[cdemcurriculum.com]
  • Symptoms may include: Severe abdominal pain Chills Fever Nausea Vomiting Shock X-rays of the chest or abdomen may show air in the abdominal cavity. This is called free air. It is a sign of a tear.[medlineplus.gov]
  • Presentation Severe abdominal pain is the presenting complaint in patients with perforated viscous. The onset of pain is sudden and accompanied by rapidly worsening overall condition.[saem.org]
  • Snap Shot A 41-year-old male with history of Crohns disease presents to the emergency departmentwith severe abdominal pain. The patient reports that he has not had a bowel movement in 24 hours. His pain continues to worsen.[medbullets.com]
Abdominal Distension
  • All of the patients presented with pain in the abdomen, 64% with vomiting, 72% with abdominal distension, 44% were febrile, 6% with shock (Table-4). 80% of patients were of low 'socio- economic status, 74% were smoker, 84% were involved in stressful job[orion-group.net]
  • The infant developed abdominal distension and bilious aspirates the following day. The abdominal radiograph at this stage was deemed “unremarkable”.[fn.bmj.com]
  • […] insufflation Douching Knee-chest exercise, water skiing, horseback riding Intraperitoneal Gas forming peritonitis Rupture of abscess Air in lesser peritoneal sac gas in scrotum (through open processus vaginalis) Imaging findings Large collection of gas Abdominal[learningradiology.com]
Abdominal Rigidity
  • Etiologies include: actute diverticulitis cancer inflammatory bowel disease ischemic bowel abdominal trauma Presentation Symptoms abdominal pain and rigidity Physical exam abdominal rigidity and rebound tenderness may exhibit "peritoneal signs" - extreme[medbullets.com]
  • Some of the clinical manifestations that lead to suspect AAP are absence of bowel sounds, bilious vomiting, involuntary abdominal guarding, rebound tenderness, abdominal rigidity and fever, when it appears after the onset of abdominal pain and emesis.[scielo.org.co]
Hypotension
  • Patients will present ill appearing with varying degrees of fever, tachycardia, tachypnea and hypotension to full blown septic shock. Patients suffering from perforated viscous have an ill to toxic appearance.[saem.org]
  • The patient is afebrile, but tachycardic and tachypneic, and has relative hypotension with systolic blood pressure in the 90s. She appears anxious, diaphoretic, and uncomfortable.[mhmedical.com]
  • Rapid contamination of the perforated site with a chemical and bacterial milieu may set up a SIRS syndrome with the patient appearing acutely toxic, significantly hypotensive, tachypneic, tachycardic and febrile.[cdemcurriculum.com]
  • These terms suggest organ dysfunction or refractory hypotension not related to an infectious etiology, but rather an ischemic, traumatic, or inflammatory process. [3] SIRS, independent of the etiology, has the same pathophysiology with minor differences[saudisurgj.org]
  • […] the General Medicine Service due to abdominal pain of 20 minutes of evolution, of sudden onset and rapid progress, located in the hypochondrium and right iliac fossa, irradiated to the ipsilateral lumbar area, associated with emesis, diaphoresis and hypotension[scielo.org.co]
Tachycardia
  • Patients will present ill appearing with varying degrees of fever, tachycardia, tachypnea and hypotension to full blown septic shock. Patients suffering from perforated viscous have an ill to toxic appearance.[saem.org]
Meningism
  • One case of acute meningitis occurred after an isolated stomach perforation, while two other patients developed psoas abscesses after colon injuries.[ncbi.nlm.nih.gov]

Workup

  • Begin antibiotics early in the workup. Anti-microbial coverage will depend on the site of the perforation. If the location of the perforation is unknown empirically cover for gram negatives, gram positives and anaerobes.[saem.org]
Pneumoperitoneum
  • BACKGROUND: In the majority of pneumoperitoneum cases we diagnose perforated viscus. We present herein a case of ruptured hepatic abscess mimicking perforated viscus.[ncbi.nlm.nih.gov]
  • Critics of plain radiography relate that 50 % of patients with a perforated viscus on laparotomy had no findings of pneumoperitoneum of plain film and that 10-14% of pneumoperitoneums may have a non surgical cause.[cdemcurriculum.com]
  • Pneumoperitoneum: a review of nonsurgical causes. Crit Care Med. 2000 Jul;28(7):2638-44. Review. Jones R. Recognition of pneumoperitoneum using bedside ultrasound in critically ill patients presenting with acute abdominal pain.[saem.org]
  • […] abdominal chest x-rays at detecting pneumoperitoneum is poor.[bestbets.org]

Treatment

  • During the past seven years 154 patients underwent PCD for treatment of abdominal abscesses.[ncbi.nlm.nih.gov]
  • Perforation of a hollow viscus is an emergency which should prompt a rapid and effective treatment.[ncbi.nlm.nih.gov]
  • The patient will most likely be kept in hospital care for several days or longer after initial treatment.[reference.com]
  • The treatment depends upon its cause as well as the location. In most cases though, drug therapy along with open surgery is recommended.[buzzle.com]
  • The importance of early prevention and treatment of sepsis has never been greater.[books.google.com]

Prognosis

  • Increased awareness of this condition is essential as rapid surgical intervention is the key factor in improving the prognosis.[elsevier.es]
  • It account 1-10% of abdominal tuberculosis cases and it has a poor prognosis with mortality rate higher than 30% [4], [5].[saudijgastro.com]
  • Prognosis A GI perforation is a medical emergency and requires quick recognition of the signs and symptoms, and rapid medical response. When this occurs, recovery should be complete.[sepsis.org]
  • Acute fungal peritonitis after perforation of gastrointestinal ulcer is a rare event and its etiology, treatments, and prognosis have not been well analyzed due to the limited number of cases.[omicsonline.org]
  • […] colon cancer, diverticulitis, stomach ulcers, ischemic bowel, C. difficile infection [2] Diagnostic method CT scan, plain X-ray [2] Treatment Emergency surgery in the form of an exploratory laparotomy [2] Medication Intravenous fluids, antibiotics [2] Prognosis[en.wikipedia.org]

Etiology

  • Etiologies of the abscesses included perforated appendicitis in six patients, sigmoid diverticulitis in three patients, Crohn's ileitis in two patients, and one case each of perforated gastric ulcer, perforated sigmoid carcinoma, and perforated gallbladder[ncbi.nlm.nih.gov]
  • These terms suggest organ dysfunction or refractory hypotension not related to an infectious etiology, but rather an ischemic, traumatic, or inflammatory process. [3] SIRS, independent of the etiology, has the same pathophysiology with minor differences[saudisurgj.org]
  • Etiologies include: actute diverticulitis cancer inflammatory bowel disease ischemic bowel abdominal trauma Presentation Symptoms abdominal pain and rigidity Physical exam abdominal rigidity and rebound tenderness may exhibit "peritoneal signs" - extreme[medbullets.com]
  • Free Intraperitoneal Air Pneumoperitoneum Etiology Disruption of wall of hollow viscus Blunt or penetrating trauma Perforating foreign body (eg, thermometer injury to rectum) Iatrogenic perforation Laparoscopy / laparotomy (58%) Absorbed in 1-24 days[learningradiology.com]
  • Helicobacter pylori is not the predominant etiology for peptic ulcers requiring operation. Am Surg 2011; 77:1054-1060. 2. Bertleff MJ, Lange JF. Perforated peptic ulcer disease: a review of history and treatment. Dig Surg 2010; 27:161-169. 3.[ejs.eg.net]

Epidemiology

  • The aim of this monograph is to summarise the currently available data regarding epidemiology, pathogenesis, and optimal management of septic shock, with a particular emphasis on the role of source control in sepsis.[books.google.de]
  • Angus' research, funded principally by the NIH, focuses on clinical, epidemiologic and translational studies of sepsis, pneumonia, and multisystem organ failure and on health services research of the organization and delivery of critical care services[books.google.de]
  • Systematic review of the epidemiology of complicated peptic ulcer disease: incidence, recurrence, risk factors and mortality. Digestion 2011; 84:102-113. 4. Williams N, Bullstrode C, Connell RO.[ejs.eg.net]
  • World J Surg 35: 2650-2659. de Ruiter J, Weel J, Manusama E, Kingma WP, van der Voort PH (2009) The epidemiology of intra-abdominal flora in critically ill patients with secondary and tertiary abdominal sepsis. Infection 37: 522-527.[omicsonline.org]
  • Epidemiology of Helicobacter pylori. Best. Pract. Res. Clin. Gastroenterol . 2007;21:205-14. . [ Links ] 14. Suebaum S, Michetti P. Helicobacter pylori infection. N. Engl. J. Med . 2002;347:1175-86. . [ Links ] 15. Hua MC, Kong MS, Lai MW, Luo CC.[scielo.org.co]
Sex distribution
Age distribution

Pathophysiology

  • This article reviews the pathophysiology, evaluation, and treatment of most of these hernias from an emergency medicine perspective.[secusa.org]
  • The possible reasons for the high mortality and morbidity rates at that time may have been related to the following factors: Knowledge in the area of bowel injuries and the pathophysiologic changes triggered by such injuries was inadequate Clinical skills[emedicine.medscape.com]
  • These terms suggest organ dysfunction or refractory hypotension not related to an infectious etiology, but rather an ischemic, traumatic, or inflammatory process. [3] SIRS, independent of the etiology, has the same pathophysiology with minor differences[saudisurgj.org]

Prevention

  • Early bullet removal did not appear to be a significant factor in the prevention of infection. Prospective studies are needed to accurately delineate the role of initial antibiotic therapy for the prevention of spinal infection in these injuries.[ncbi.nlm.nih.gov]
  • Knowledge of the mechanism and differential diagnosis of this entity will prevent overlooking this possibility, as occurs too frequently, particularly with subcutaneous emphysema of the leg.[ncbi.nlm.nih.gov]
  • Rapidly find the answers you need with separate sections on diseases and disorders, differential diagnosis, clinical algorithms, laboratory results, and clinical preventive services, plus an at-a-glance format that uses cross-references, outlines, bullets[books.google.com]
  • To prevent fatal complications due to bacteria all patients are administered antibiotics.[ic.steadyhealth.com]
  • The importance of early prevention and treatment of sepsis has never been greater.[books.google.com]

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