This patient presented with right flank pain and abdominal distension. Imaging showed cholelithiasis and perforated abdominal viscus. She underwent classical Graham's patch repair for duodenal ulcer perforation. Post-operatively, she developed septic shock, metabolic acidosis, and hypoglycemia. She was deemed to have a poor prognosis and died from septic shock secondary to duodenal ulcer perforation peritonitis, which was exacerbated by the surgical stress of the repair procedure.

2. Morbidity Case Discussion

3. Patient Details
• Hospital number: 890222/A887540
• Name: Dala Ram Ghale
• Age: 51 years
• Sex: Male
• Address: Gorkha
• Jehovah’s witness

4. Past Medical/Surgical History
• Urinary TB X 15 years back (treatment completed)
• Open ureterotomy with DJ stenting (2064) for right ureteric stone + NFLK +
UB TB
• Lapaoscopic left nephrectomy (Bhadra, 2078)
• Indication: non-functioning left kidney with h/o left pyonephrosis with
PCN placement
• Biopsy: Chronic pyelonephritis
• Hypertension (under medication)

5. Past Surgical History
• Right pyelonephritis with hydronephrosis (Shrawan 2080)
• Failed attempt of right URSL (distorted anatomy of UB and non
visualization of ureteric orifice) – 2080/04/05
• PCN placement for 2080/04/05
• Failed attempt of ureteroscopy 2080/04/09
• Antergrade right pyelogram (2080/05/05): recoil of guidewire beyond VUJ
• Cystogram (2080/05/18): small capacity bladder
• Planned for Augmentation cystoplasty vs Ileal conduit

6. Clinical Course
• Presented at ER on 2080/06/02 with c/o
• Fever X 3 days, Tmax 103.4oF
• Right flank and lower abdominal pain
• Burning micturition, increased urinary frequency, hematuria Right renal
angle tenderness, suprapubic tenderness
• O/E
• General physical examination: unremarkable ; Vitals stable
• P/A: suprapubic tenderness, right renal angle tenderness
• Systemic examination unremarkable

7. Clinical Course
• Investigations:
• Normal WBC count
• RFT: 58/2.9/134/4
• Urine R/E: pus cells packed, albumin 1+
• Urine c/s: No growth
• USG A+P (2080/06/02)
• Post-left nephrectomy status
• Simple left renal cortical cyst (thin walled 3.7 X 3.1 cm in upper pole
cortex with single thin septation)

8. Clinical Course
• Admitted in Surgery Ward
• Provisional diagnosis: Complicated UTI
• Conservative management
• Conditions improved
• Discharged on HAD 5 (2080/06/06) on oral antibiotics

9. Clinical Course
• Presented again at ER on 2080/06/16 with c/o
• Fever X 7 days, Tmax 101oF
• Burning micturition, hematuria, oliguria, increased urinary frequency
• Right lower quadrant pain and right flank pain, Nausea
• O/E
• General physical examination: unremarkable
• Hemodynamically stable
• Right renal angle tenderness +
• Systemic examination unremarkable

10. Clinical Course
• Investigations at this presentation: Urea/Cr 46/2/6
• Normal counts
• RFT: Urea/Cr/Na/K: 46/2.6/139/4.1
• Urine RME: pus 8-10, albumin trace
• Re-admission in Surgery Ward
• Provisional diagnosis: Complicated UTI
• Temp. charting: daily single spike of fever, Tmax 101.2oF, intermittent pattern

11. Surgery
• Augmentation cystoplasty with right ureteric reimplantation (2080/06/18)
• With right DJ stenting and SPC placement
• Abdominal drain placement
• Intraoperative findings:
• Right VUJ stricture
• Right ureteric orifice could not be negotiated with guide wire
• Small capacity bladder

12. Post-operative Period
• Post-operative SICU transfer
• Indication:
• Staged extubation
• Hemodynamic monitoring
• pain management
• 2 days of SICU stay - unremarkable
• Shifted to S-HDU

13. Post-operative Period
• NG free drain removed on POD 4
• Suspected anastomotic leak POD 10
• Re-exploration with double barrel ileostomy for anastomotic leak
(2080/06/??28)
• Improving condition
• Drain out POD 13
• Developed SSI (E. coli) – started on antibiotics as per c/s, daily dressing
changes
• Shifted to Ward on POD 14

14. Post-operative Period
• Foley removed on 3rd week post-op
• Discharged on 2080/07/12
• RFT at discharge (64/2.3/132/4.6)
• Ileostomy functioning
• Wound status: improving

15. Clinical Course
• Presented at ER after 6 days of discharge (on 2080/07/18) with c/o
• Fever X 2 days, Tmax: 102oF
• Multiple ep. of non-bilious vomiting X 1 day
• O/E
• General physical examination: unremarkable
• Vitals stable
• P/A: soft, non-distended, positive right renal angle tenderness
• Systemic examination: unremarkable
• Ileostomy functioning

16. Clinical Course
• Investigations at this presentation:
• Leukocytosis
• RFT : 117/4.8/124/5.7
• Urine c/s: significant growth of Klebsiella aerogenes (sensitive only to
doxycycline)
• USG A+P
• Right kidney: thin walled cystic lesions, largest 3.4 X 37 cm in upper
pole (s/o simple renal cyst); at least two calculi largest measuring upto
12 mm in lower pole
• Left kidney not visualized; Limited pelvic scan due to colostomy bag

17. Clinical Course
• Provisional diagnosis: Urosepsis
• Admitted in S-HDU
• Conservative management
• Inj. Meropenem later switched to Cap. Doxycycline as per c/s
• Nutritional evaluation (25% unintentional weight loss in 1 month)
• Shifted to ward on HAD 3
• Discharged on HAD 8 (2080/07/25)

18. Follow-up
• OPD (5th week post-op)
• PVC removed (2080/08/01)
• Retention suture removed (2080/08/01)
• RFT (107/2.6/133/4.7)
• OPD (6th week post-op)
• Urine c/s (2080/08/04) : Klebsiella r/t fluoroquinolones, carbapenem,
aminoglycoside
• USG (2080/08/08): PVRU 57.2 ml

20. Mortality Case 1
• Name: Man Kumari Shrestha
• Ag/Sex: 79 Y/F
• Hospital no.: 970584
• Date of admission: 2080/05/29
• Date of mortality: 2080/06/12

21. • Presented to ER with c/o
• Anorexia X 4 days
• Yellowish discoloration X 2days
• Right upper quadrant abdominal pain, non-radiating
• Significant history of alcohol consumption, smoker
• h/o PPI use for acute gastritis
• O/E : Ill-looking, cachectic, icteric
• BP 90/40, HR 80bpm, afebrile, spO2 maintained in RA
• P/A: palpable tender mass in RUQ, hard consistency, non mobile, well
defined margins

22. • Investigations:
• TLC 24,800 (N93 L7)
• Hb/Hct 7.1 / 23%
• Plt 565k
• Urea/Cr 59/1.2
• Na/K 140/2.3 – 2.8
• Bili T/D 28/17.2
• SGOT/SGPT 336/96
• ALP 793
• CEA 230 / CA 19.9 26.9
• PT/INR 23.8/1.83

23. • ECG: RV strain pattern, cardiac markers normal
• Echo : EF 55%, grade I LV diastolic dysfunction with raised LVEDP, Mild AR,
mild TR with mild PAH, no RWMA
• USG (A+P): Dilated CBD and IHBD, multiple hyperechoic lesion in liver, likely
mets, distended GB with GB sludge, mild ascites
• CECT A+P (06/01):
• Mass in periampullary region; MPD, CBD, IHBD dilated
• Multiple hypodense lesion in liver ? Mets
• Distended GB
• Mild ascites

24. • Admitted in SICU
• Provisional diagnosis: Acute severe cholangitis
• Supplemental O2, ionotrope support
• Electrolytes corrected
• II pint WB / I pint FFP transfused
• Nutritional assessment: moderate malnutrition (Alb 2.2 / T. protein 5.5)
• TPN started
• Shifted to S-HDU after 9 days of SICU stay

25. • ERCP (2080/06/05)
• Scope not negotiated beyond D1 due to deformity and narrowing
• PTBD advised
• For referral to other center due to unavailability at PAHS)
• Refused
• Developed MOD
• Condition deteriorated
• Signed DNI/DNR

26. • Date of mortality: 2080/06/12, 6:05 pm
• Cause of death: Multiple organ dysfunction secondary to acute severe
cholangitis
• Contributing cause: Periampullary carcinoma with liver mets

28. Mortality Case 2
• Name: Dil Bahadur Ghalan
• Age/Sex: 59 Y/M
• Address: Lalitpur
• Hospital no.: 970233 / A1469673 / EG94655
• Date of admission: 2080/05/25
• Date of mortality: 2080/06/19

29. • Presented at ER with c/o
• Not passing stool/ flatus X 2 days
• Abdominal distention X 2 days
• Generalized abdominal pain
• Vomiting
• h/o on/off fever, anorexia and unintentional weight loss X 3 months
• No known comorbidities
• Smoker, significant h/o alcohol consumption

30. • O/E
• GC: ill looking, pale, icteric
• P/A: distended, tenderness in right hypochondrium, BS +
• DRE: palpable soft mass in rectum, enlarged prostate, non-tender,
normal anal tone
• Proctoscopy: ulceroproliferative growth on rectal mucosa
• Investigations
• Leukocytosis
• Deranged LFT

31. • USG A+P (2080/05/25, report from outside): hepatomegaly with multiple
abscess, gross free fluid in peritoneal cavity
• Admitted in Surgery Ward ; Provisional diagnosis: Subacute bowel
obstruction secondary to ? Ca rectum with hepatic abscess
• USG-guided pigtail catheter drain placed on HAD 6
• Findings: subcapsular collection 662 ml communicating with
intrahepatic collection
• Fluid c/s: no growth
• Conservative management

32. • CECT A+P (2080/06/02)
• Large well defined hypodense inraparenchymal multiloculated cystic
lesion with irregular inner wall in liver – likely abscess
• Irregularly outlined wide mouth gas filled focal outpouchig from gastric
antrum – likely diverticulum
• Moderate ascites
• Multiple patchy consolidations in basal segments of right lower lobe –
likely infective
• No definitive bowel thickening/abnormal enhancement noted within
rectosigmoid region

33. • Improving conditions, planned for discharge
• Sudden deterioration in condition on HAD 14
• Shifted to SICU
• Sudden drop in Hb. 5.8 – IV pint PRBC transfusion
• UGI endoscopy (preliminary reporting): adherent clot with ulcer
• Colonoscopy(2080/06/09) - suboptimal scan
• Multiple ulcerated areas at ascending colon and caecum; suspicious
lesion at rectosigmoid region with large amount of black stool
• Rectal biopsy: Non-specific colitis

34. • Conservative management; Condition improved
• Shift to S-HDU after 2 days of SICU stay
• Profuse UGI bleeding on 3rd week of HA
• Rapid fall in BP with decreasing O2 sat
• Shifted to ICU - Intubated, ionotropes support
• Worsening condition
• DNR signed in view of poor prognosis
• Asystole

35. • Date of mortality: 2080/06/19, 5:43 am
• Cause of death: Refractory hypovolemic shock secondary to upper GI
bleeding
• Contributing cause: gastric ulcer with ?Ca rectum with hepatic abscess

37. Mortality Case 3
• Name: Beli Maya Bholan
• Age/Sex: 66 Y/F
• Address: Makwanpur
• Hospital no 972356 / EG 131708
• Date of admission: 2080/06/18
• Date of mortality : 2080/06/20

38. • Presented at ER with c/o
• Right flank pain X 15 days
• Abdominal distension
• Multiple episodes of non-bilious vomiting
• O/E
• GC fair, edema +
• BP 100/40, HR 96, spO2 maintained in RA, afebrile
• P/A: soft, generalized tenderness, rebound tenderness +

39. • Investigations:
• Leukocytosis
• High lactate
• Raise CRP
• USG A+P (2080/06/16, report from outside): multiple chlolelithiasis,
mesenteric lymphadenopathy

40. • CECT A+P (2080/06/31??, report from outside)
• Contracted GB with cholelithiasis
• Diffuse hyperenhancing mucosa with thickening of gastric wall ?
Infammatory pathology
• Moderate ascites with subdiaphragmatic and perihepatic free air giving
air fluid level – s/o perforated abdominal viscus
• Admitted in ICU

41. • OT: Classical graham’s patch repair (2080/06/19)
• Plastered abdomen
• Fresh food content in peritoneal cavity
• Duodenal ulcer perforation 2.5 X 1.5 cm in anterior 1st part of
duodenum
• Thickened and caked greater omentum
• Drain placed in Morrison’s pouch and in pelvis
• Intraop hypoglycemia (51mg/dl) - corrected

42. • Post-op shifted to ICU : Intubated, ionotropes support
• POD 1
• ABG: metabolic acidosis
• Septic shock
• Poor prognosis – DNR signed
• 12 MN: Hypoglycemia (GRBS 25mg/dl) –corrected
• 4:05 am: Bradycardia then aystole
• Death declared: 2080/06/20, 4:21 am

43. • Date of mortality: 2080/06/20, 4:21 am
• Cause of death: Septic shock secondary to duodenal ulcer perforation
peritonitis
• Contributing cause: Surgical stress - Classical Graham’s patch repair