Case presentation on Iatrogenic perforation

1. CASE PRESENTATION
Dr. Rushdan Zakariah
Intern Doctor
Surgery Department,
Purple Unit

2. 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

3. 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.

4. 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

5. General Examination:
Appearance: Toxic
Body built: Average
Co operation: Co operative
Decubitus: Supine
Nutrition: Good
Anemia: Absent
Jaundice: Absent
Cyanosis: Absent
Clubbing: Absent
Koilonychia: Absent
Leuchonychia: Absent
Edema: Absent
Dehydration: Absent
Thyroid Glands: Not palpable
Lymph Nodes: Not enlarged
Neck Veins: Not engorged
Swellings: Absent
BP: 130/80 mm Hg
Pulse: 120 beats / min
Temperature: 99º F
Respiratory rate:
28 breaths / min

6. 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

7. 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

8. 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

9. So, What is the diagnosis ????

10. 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

11.  CXR – P/A view

12.  X ray of abdomen E/P

13.  USG of whole abdomen

14.  USG of whole abdomen

15. Final Diagnosis:
Iatrogenic Perforation

16. Immediate Management :
 Patient was kept NPO
 I/V Fluid was given 3000 cc
 NG Suction was done 4 hourly
 Broad spectrum antibiotics were started
 Analgesic
 Anti ulcerant
 Anti emetic
 Transfusion of 2 units of whole fresh blood
 Continuous catheterization & strictly
maintenance of I/O chart

17. 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.

18. Per Operative Photograph:

19. Post Operative Management :
 NPO for 3 days
 NG Suction 4 hourly
 I/V Fluid – 3000 cc
 Broad spectrum antibiotics – Ceftriaxon,
Metronidazole & Amikacin
 Analgesic
 Anti ulcerant
 Anti emetic

20. 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 cc
3rd POD: Vitals - Good
Serum K – 2.9 mmol / l
Inj. KCl (2 amp) was given in normal saline
Dressing was done

21. 4th POD: Diet – Sips of water
Drain – 70 cc
Temp – 99 degree F
5th POD: Diet – Clear liquid followed by soft rice
Drain – 40 cc
Patient developed diarrhoea
Ranitidine was given instead of Omeprazole
6th POD: Drain tubes and catheter were removed
Diet – Regular
Dressing was done
7th,8th and 9th POD: Improvement of diarrhoea
10th POD: Delayed primary suture was given & 1 drain was kept
in situ
11th POD: Patient is improving & doing good

22. 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.

23. Thank you for your patience
hearing and time.