case presentation on iatrogenic perforation

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.