Perforation of the gastrointestinal tract may be suspected based upon the patient’s clinical presentation, or the diagnosis becomes obvious through a report of extra luminal “free” gas or fluid or fluid collection on diagnostic imaging performed to evaluate abdominal pain or another symptom. Clinical manifestations depend somewhat on the organ affected and the nature of the contents released (gas, succus entericus, stool), as well as the ability of the surrounding tissues to contain those contents. Intestinal perforation can present acutely or in an indolent manner (e.g., abscess or intestinal fistula formation). A confirmatory diagnosis is made primarily using abdominal imaging studies, but on occasion, exploration of the abdomen (open or laparoscopic) may be needed to make a diagnosis. Specific treatment depends upon the nature of the disease process that caused the perforation. Some etiologies are amenable to a nonoperative approach, while others will require emergent surgery.
This document discusses enterocutaneous fistulas, including:
1. Fistulas are abnormal connections between two epithelial surfaces, most commonly occurring after abdominal surgery as a complication.
2. Classification systems include etiologic (cause), anatomic (location), and physiologic (output amount) which provide understanding for management.
3. Prevention focuses on proper preoperative patient preparation and surgical technique to reduce postoperative fistula risks.
This document summarizes gallstone ileus, a rare complication of cholelithiasis where a gallstone passes through a biliary-enteric fistula and becomes lodged in the gastrointestinal tract, causing a bowel obstruction. It first describes the pathophysiology involving long-standing inflammation leading to a fistula formation. Clinical features include symptoms of bowel obstruction as well as prior biliary symptoms. Diagnosis is typically made using CT imaging showing the obstructing gallstone, fistula, and other signs. Treatment involves surgically removing the gallstone through an enterolithotomy, with some cases also requiring closure of the fistula and cholecystectomy. There is debate around performing these procedures simultaneously or in staged surger
Autors: Richard M. Gore, MD*, Robert I. Silvers, MD, Kiran H. Thakrar, MD,
Daniel R. Wenzke, MD, Uday K. Mehta, MD, Geraldine M. Newmark, MD,
Jonathan W. Berlin, MD
Abstract
This case report describes the diagnosis and management of a large mesenteric cyst in a 55 year old lady who presented with abdominal distension & with mass in the left upper quadrant. Mesenteric cysts are rare, benign, abdominal tumors to which <1000 cases have been reported in the literature. While 40% of cases are incidental findings found either through physical examination or imaging, they can cause non-specific abdominal symptoms including pain, altered bowel habits, nausea/vomiting or anorexia. Less commonly, 10% of cases can present with bowel obstruction, volvulus, torsion or shock. In general, the lack of characteristic clinical and radiological features presents as a diagnostic difficulty.
The mainstay in imaging is computerized tomography (CT). CT identifies and helps aid the decision to pursue a laparoscopic or open laparotomy approach, where complete surgical resection is the ultimate goal. In our patient a CT Abdomen & Pelvis showed a large, loculated cystic mass measuring 30cm in cranio-caudal length and 16cm in the transverse and anterior/posterior diameter. While different approaches have been described in the literature to surgically resect such cysts, our approach was largely reflective of size and adherence to surrounding structures in this case. A laparotomy was performed using an upper mid-line 7 cm incision; 4500cc of fluid was aspirated from the cyst which was found to originate from the small bowel mesentery. A complete resection of the multi-loculated cystic sac was done that included the resection of the middle mesenteric vein. The post-operative period was uneventful. The patient was discharged on post-operative day 2. The Histopathology identified the mass as a multi-loculated peritoneal inclusion-type cyst.
Crimson Publishers-A Newborn Presenting With Bilious Vomiting: A Case Report...CrimsonPublishersAICS
Jejunal atresia is a rare cause of small bowel obstruction in newborns, occurring in approximately 1-3 per 10,000 live births. It is caused by in utero vascular insult and presents with abdominal distention and bilious vomiting. Imaging shows dilation of the stomach and proximal small bowel loops ("triple bubble" sign). An upper gastrointestinal study can determine the level of obstruction and rule out malrotation/midgut volvulus, which is a surgical emergency. Surgical resection of the atretic bowel segment and primary anastomosis is the definitive treatment.
The esophageal duplication cyst is a congenital defect of the digestive tract. It has an estimated prevalence of 0.012%, with higher predominance in males. Although it is a common fi nding in children, diagnosis of an esophageal duplication in adults is rare. Following ileal duplication, esophageal is the second most common duplication of the gastrointestinal tract, representing the 10-15% of all gastrointestinal duplication defects. For esophageal duplication, there are two main variants: cystic and tubular, the latter being the least common. They are usually developed during the third to fifth week of gestation due to failure of the vacuolar coalescence. Duplication cysts are commonly located in the distal third of the esophagus.Treatment should always be surgical, even at the asymptomatic stage
of disease, given the possibility of symptom development and complication appearance. Here we present a case of an adult patient presenting with an esophageal duplication cyst with a brief literature review.
Tips and Tricks in Laparoscopic Dissection of AdhesionsGeorge S. Ferzli
The document provides information on laparoscopic dissection of adhesions. It discusses the historical perspectives on adhesions, adhesion pathophysiology, prevention of adhesion formation, complications related to adhesions, results of laparoscopic adhesiolysis for small bowel obstruction, operating room set up, laparoscopic management indications and outcomes, laparoscopic approach, peritoneal access and potential trocar injury, optical access trocars, and recommended tools for adhesiolysis.
This document provides background information and summarizes key principles regarding acute appendicitis. It begins by discussing the appendix's role in the digestive system and risk factors for appendicitis. The anatomy and pathophysiology of appendicitis are then described, noting that obstruction of the appendix is the underlying cause. Common presenting symptoms are reviewed, emphasizing that the classic presentation is seen in less than 50% of cases, making diagnosis challenging. Differential diagnoses and the role of laboratory tests, imaging, and clinical assessment in evaluation are also summarized. Throughout, it is stressed that diagnosis relies on integrating multiple factors rather than any single finding.
This document discusses enterocutaneous fistulas, including:
1. Fistulas are abnormal connections between two epithelial surfaces, most commonly occurring after abdominal surgery as a complication.
2. Classification systems include etiologic (cause), anatomic (location), and physiologic (output amount) which provide understanding for management.
3. Prevention focuses on proper preoperative patient preparation and surgical technique to reduce postoperative fistula risks.
This document summarizes gallstone ileus, a rare complication of cholelithiasis where a gallstone passes through a biliary-enteric fistula and becomes lodged in the gastrointestinal tract, causing a bowel obstruction. It first describes the pathophysiology involving long-standing inflammation leading to a fistula formation. Clinical features include symptoms of bowel obstruction as well as prior biliary symptoms. Diagnosis is typically made using CT imaging showing the obstructing gallstone, fistula, and other signs. Treatment involves surgically removing the gallstone through an enterolithotomy, with some cases also requiring closure of the fistula and cholecystectomy. There is debate around performing these procedures simultaneously or in staged surger
Autors: Richard M. Gore, MD*, Robert I. Silvers, MD, Kiran H. Thakrar, MD,
Daniel R. Wenzke, MD, Uday K. Mehta, MD, Geraldine M. Newmark, MD,
Jonathan W. Berlin, MD
Abstract
This case report describes the diagnosis and management of a large mesenteric cyst in a 55 year old lady who presented with abdominal distension & with mass in the left upper quadrant. Mesenteric cysts are rare, benign, abdominal tumors to which <1000 cases have been reported in the literature. While 40% of cases are incidental findings found either through physical examination or imaging, they can cause non-specific abdominal symptoms including pain, altered bowel habits, nausea/vomiting or anorexia. Less commonly, 10% of cases can present with bowel obstruction, volvulus, torsion or shock. In general, the lack of characteristic clinical and radiological features presents as a diagnostic difficulty.
The mainstay in imaging is computerized tomography (CT). CT identifies and helps aid the decision to pursue a laparoscopic or open laparotomy approach, where complete surgical resection is the ultimate goal. In our patient a CT Abdomen & Pelvis showed a large, loculated cystic mass measuring 30cm in cranio-caudal length and 16cm in the transverse and anterior/posterior diameter. While different approaches have been described in the literature to surgically resect such cysts, our approach was largely reflective of size and adherence to surrounding structures in this case. A laparotomy was performed using an upper mid-line 7 cm incision; 4500cc of fluid was aspirated from the cyst which was found to originate from the small bowel mesentery. A complete resection of the multi-loculated cystic sac was done that included the resection of the middle mesenteric vein. The post-operative period was uneventful. The patient was discharged on post-operative day 2. The Histopathology identified the mass as a multi-loculated peritoneal inclusion-type cyst.
Crimson Publishers-A Newborn Presenting With Bilious Vomiting: A Case Report...CrimsonPublishersAICS
Jejunal atresia is a rare cause of small bowel obstruction in newborns, occurring in approximately 1-3 per 10,000 live births. It is caused by in utero vascular insult and presents with abdominal distention and bilious vomiting. Imaging shows dilation of the stomach and proximal small bowel loops ("triple bubble" sign). An upper gastrointestinal study can determine the level of obstruction and rule out malrotation/midgut volvulus, which is a surgical emergency. Surgical resection of the atretic bowel segment and primary anastomosis is the definitive treatment.
The esophageal duplication cyst is a congenital defect of the digestive tract. It has an estimated prevalence of 0.012%, with higher predominance in males. Although it is a common fi nding in children, diagnosis of an esophageal duplication in adults is rare. Following ileal duplication, esophageal is the second most common duplication of the gastrointestinal tract, representing the 10-15% of all gastrointestinal duplication defects. For esophageal duplication, there are two main variants: cystic and tubular, the latter being the least common. They are usually developed during the third to fifth week of gestation due to failure of the vacuolar coalescence. Duplication cysts are commonly located in the distal third of the esophagus.Treatment should always be surgical, even at the asymptomatic stage
of disease, given the possibility of symptom development and complication appearance. Here we present a case of an adult patient presenting with an esophageal duplication cyst with a brief literature review.
Tips and Tricks in Laparoscopic Dissection of AdhesionsGeorge S. Ferzli
The document provides information on laparoscopic dissection of adhesions. It discusses the historical perspectives on adhesions, adhesion pathophysiology, prevention of adhesion formation, complications related to adhesions, results of laparoscopic adhesiolysis for small bowel obstruction, operating room set up, laparoscopic management indications and outcomes, laparoscopic approach, peritoneal access and potential trocar injury, optical access trocars, and recommended tools for adhesiolysis.
This document provides background information and summarizes key principles regarding acute appendicitis. It begins by discussing the appendix's role in the digestive system and risk factors for appendicitis. The anatomy and pathophysiology of appendicitis are then described, noting that obstruction of the appendix is the underlying cause. Common presenting symptoms are reviewed, emphasizing that the classic presentation is seen in less than 50% of cases, making diagnosis challenging. Differential diagnoses and the role of laboratory tests, imaging, and clinical assessment in evaluation are also summarized. Throughout, it is stressed that diagnosis relies on integrating multiple factors rather than any single finding.
An intestinal obstruction occurs when your small or large intestine is blocked. The blockage can be partial or total, and it prevents passage of fluids and digested food. If intestinal obstruction happens, food, fluids, gastric acids, and gas build up behind the site of the blockage.
Evaluation and management of intestinal obstructionImad Zoukar
This document discusses the evaluation and management of intestinal obstruction. Key points include:
- Intestinal obstruction is most commonly caused by adhesions, malignancy, or herniation and presents with abdominal pain, nausea/vomiting, and inability to pass gas/stool.
- Diagnostic testing includes abdominal x-rays, which show dilated bowel loops in 60% of cases, and CT scan, which is more sensitive and can identify the level and cause of obstruction.
- Management involves fluid resuscitation, bowel rest with nasogastric decompression, and surgery if there is evidence of vascular compromise, perforation, or failure to resolve with conservative measures.
Cysts of the mesentery are among surgical rarities and of varied aetiology with variable presentations and
this has surgical implications in the pediatric age group. They may be derived from the gastrointestinal
tract, the genitourinary system, previous inflammation (pseudocysts) or malignant cystic tumours, but the
commonest cause is generally considered to be a congenital lymphatic cyst. The clinical presentation is not
characteristic and in addition, the preoperative imaging although suggestive is not diagnostic. In most
cases, the diagnosis is confirmed after surgical exploration and removal of the cyst. A case report of a
baby aged 6 months is being reported. Hope that this information will reinforce the diagnostic and
treatment strategy
Lipoma of the Small Intestine: A Cause for Intussusception in AdultsKETAN VAGHOLKAR
This case report describes a rare case of small intestinal intussusception in a 22-year-old male patient caused by a lipoma. Imaging including ultrasound and CT scan revealed the classic signs of intussusception and identified a likely lipoma as the cause. During surgery, an ileoileocolic intussusception was found and gently reduced, finding a submucosal lipoma as the pathological lead point. The involved intestinal segment containing the lipoma was resected. Histopathological examination confirmed the diagnosis of benign submucosal lipoma. The patient recovered well with no further symptoms.
Bouveret's syndrome as an unusual cause of gastric outletFerstman Duran
This case report describes an 83-year-old man who presented with vomiting and abdominal pain and was found to have Bouveret's syndrome. Endoscopy revealed a large mass obstructing the duodenum, which was discovered to be a gallstone during surgery. The gallstone had caused a cholecysto-duodenal fistula. Initial surgery removed the fistula but the gallstone remained, requiring a second surgery to remove it from the duodenum. Bouveret's syndrome is a rare complication of gallstones that can cause gastric outlet obstruction.
Surgical Complications of Roundworm InfestationKETAN VAGHOLKAR
Round worm infestation is common in the tropical countries. Ascaris lumbricoides can cause a variety of complications in the abdomen ranging from colic to perforative peritonitis. As majority of abdominal complications require surgical intervention awareness of the complications is pivotal to the attending surgeon. The surgical complications of roundworm infestation are discussed in this article.
This document proposes a clinical algorithm for managing open abdomen with concomitant entero-atmospheric fistula (EAF), a surgical complication with high mortality. The algorithm aims to guide surgeons in choosing the best approach on a case-by-case basis. EAF is defined as an enteric fistula occurring within an open abdomen, lacking a tract and surrounding tissue. Current management techniques aim to divert fistula output, protect viscera, and allow bowel granulation. However, no single approach is ideal and significant heterogeneity exists. The document reviews various techniques and proposes a flowchart to help select the optimal individualized strategy. It also provides a detailed description of a "baby bottle nipple diversion" technique developed by the
Injuries to bowel and mesentery. Lecture pptxShashi Prakash
The document discusses traumatic injuries to the bowel and mesentery from blunt abdominal trauma. It notes that the bowel and mesentery are commonly injured structures after the liver and spleen. Delayed diagnosis of 8 hours or more of bowel and mesenteric injuries can result in severe complications like bleeding, peritonitis, and sepsis. CT scans are important for diagnosis as they can identify signs of intestinal perforation, bleeding, or vascular injuries that require immediate surgery. The most common sites of bowel injury are the small bowel, particularly the proximal jejunum and distal ileum. Colon injuries from blunt trauma are less common.
This document discusses acute intestinal obstruction, including classifications, causes, clinical features, investigations and treatments. It classifies obstruction based on origin, method of occurrence, blood flow and clinical course. Mechanical obstruction is distinguished from functional obstruction. Signs of small bowel obstruction include abdominal pain, nausea, vomiting and distention. Large bowel obstruction causes dull abdominal cramps and distention. Treatment involves decompression, fluid resuscitation, antibiotics and surgery to remove obstructions and non-viable bowel segments.
Laparoscopic Excision of Foregut Duplication Cyst of StomachApollo Hospitals
Retroperitoneal gastric duplication cysts lined by ciliated columnar epithelium are extremely rare lesions and its presentation during adulthood is a diagnostic challenge for treating clinicians. This entity often resembles cystic pancreatic neoplasm, retroperitoneal cystic lesions and sometimes as an adrenal cystic neoplasm. Correct diagnosis on the basis of radiological investigation is difficult and histopathologic analysis. We report a case of gastric duplication cyst in a 16year old girl that mimicked as a retroperitoneal /pancreatic /adrenal cystic lesion and was successfully managed by laparoscopy.
This document discusses a case of intestinal obstruction in a patient with a history of colon cancer. It provides background on the patient's symptoms and signs, including abdominal pain and distention, vomiting, and hemoccult-positive stool. The next steps are described as an abdominal series to determine the level and severity of obstruction. The pathophysiology of mechanical bowel obstruction is traced, involving distention, pain, potential ischemia and necrosis. Nursing management focuses on acute pain, risk for deficient fluid volume, risk for imbalanced nutrition, and ineffective tissue perfusion monitoring.
Case presentation volvulus in geriatric patientReynel Dan
1. The document presents a case of intestinal obstruction in a geriatric patient, discussing the etiology, pathophysiology, signs and symptoms, and nursing care for intestinal obstruction.
2. Intestinal obstruction can be caused by adhesions, hernias, tumors, or volvulus and results in a blockage of intestinal contents that increases pressure and risk of ischemia in the bowel.
3. Nursing care focuses on pain management, fluid resuscitation, monitoring for complications like peritonitis, and supportive care until the obstruction can be resolved medically or surgically.
Peritoneal carcinomatosis represents a devastating form of cancer progression with a very poor prognosis. Its complex pathogenesis is represented by a dynamic process comprising several steps. To the best of our knowledge pathogenesis can be partly explained by 3 major molecular pathways 1 dissemination from the primary tumor 2 primary tumor of peritoneum and 3 independent origins of the primary tumor and peritoneal implants. These are not mutually exclusive and combinations of different mechanisms could occur inside a single case. There are still several aspects which need explanation by future studies. A comprehensive understanding of molecular events involved in peritoneal carcinomatosis is of paramount importance and should be systematically pursued not only to identify novel strategies for the prevention of the condition, but also to obtain therapeutic advances, through the identification of surrogate markers of prognosis and development of future molecular targeted therapies. Mrs. Karpagam | Govinda Raj U "Peritoneal Carcinomatosis: A Case Report" Published in International Journal of Trend in Scientific Research and Development (ijtsrd), ISSN: 2456-6470, Volume-7 | Issue-4, August 2023, URL: https://www.ijtsrd.com/papers/ijtsrd59721.pdf Paper Url:https://www.ijtsrd.com/medicine/nursing/59721/peritoneal-carcinomatosis-a-case-report/mrs-karpagam
This document discusses colostomies, including reasons they may be needed such as cancer of the large intestine, perforated diverticulitis, Crohn's disease, and ulcerative colitis. It provides details on the anatomy and function of the digestive tract. The document is intended as an educational tool for healthcare professionals and discusses the physiological, surgical, practical, psychological, and social implications of living with a colostomy. It was created by Coloplast as part of their DialogueEducation materials and engagement with stoma nurses and patients.
Omental torsion: a rare cause of acute abdomenKETAN VAGHOLKAR
Torsion of the greater omentum is one of the rare causes of acute abdomen. However with an increase in the incidence of obesity in urban population there is a steady increase in the incidence of this rare and deceptive abdominal condition. The attending surgeon needs to be aware of this condition especially when confronted with an obese patient presenting as an acute abdomen. The paper reviews the etiopathogenesis and management of this rare condition.
This document discusses obstetrics and gynecology articles related to massive vaginal vault prolapse and enterocele. It provides definitions and descriptions of pelvic organ prolapse, including its causes, symptoms, diagnosis, and treatment. Pelvic organ prolapse is defined as the descent of the anterior vaginal wall, posterior vaginal wall, uterus, or vaginal vault. Causes can include childbirth injuries or surgery that damage pelvic floor muscles and nerves. Symptoms vary but may include a feeling of pressure or fullness in the pelvis. Diagnosis involves examination and sometimes tests like ultrasound or manometry. Treatment aims to regulate bowel movements and strengthen pelvic floor muscles through exercises or devices.
PowerPoint presentation on Choledochal Cysts, also known as biliary cyst, uploaded by Dr. Vaskar Humagain, first presented in 31st December, 2013. This presentation contains all the information about Choledochal Cysts, the original and revised Todani classification of choledochal cysts, pathogenesis, other associated congenital anomalies, clinical features in infant and adult, management of choledochal cysts. Comments are highly welcome :)
This document discusses postoperative complications that can occur after ulcerative colitis surgery involving an ileal pouch-anal anastomosis (IPAA). It describes several categories of complications, including surgical/mechanical issues like anastomotic leaks, pelvic sepsis, fistulae and strictures. It also discusses inflammatory disorders such as pouchitis, cuffitis and irritable pouch syndrome. Crohn's disease of the pouch is another possible complication, and the document provides criteria for differentiating this from backwash ileitis. Treatment options are mentioned for several of the complications.
Water sources and management practices among the household residents of Baran...Open Access Research Paper
The purpose of this study is to determine the water sources and management practices among the household residents of Barangay Labuyo, Tangub City, Misamis Occidental. A total of 204 household respondents were randomly interviewed using a survey questionnaire. Data on water management practices were measured using a 5-point Likert scale. One-way ANOVA and Pearson correlation were further used to determine the differences and relationships between demographic profiles and management practices. Results show that pipe water supply from the main source (68%) was the primary water source used among household residents. In terms of sex, females often practice water management on the water sources with a weighted mean of 3.42. While respondents with age 68 years and older exhibit a higher degree (weighted mean=3.63) of involvement in water conservation measures. And respondents with college degree have applied their in-depth comprehension and knowledge on water conservation with a weighted mean of 3.48. The study also revealed a significant difference in the management practices between two sexes, among all ages and levels of educational attainment with p values <0.05. The association between demographic profiles with management practices further presents a significant relationship. Generally, the demographic profile (sex, age, and educational attainment) has a weak positive relationship towards management practices with values, r = 0.26, p = 0.00021; r = 0.34, p = <0.05; and r = 0.26, p = 0.00014, respectively. Thus, results suggest the need for enhancing community awareness on sustainable water source management and putting it into practice consequently reducing inadequacy of water supply in the area.
The modification of an existing product or the formulation of a new product to fill a newly identified market niche or customer need are both examples of product development. This study generally developed and conducted the formulation of aramang baked products enriched with malunggay conducted by the researchers. Specifically, it answered the acceptability level in terms of taste, texture, flavor, odor, and color also the overall acceptability of enriched aramang baked products. The study used the frequency distribution for evaluators to determine the acceptability of enriched aramang baked products enriched with malunggay. As per sensory evaluation conducted by the researchers, it was proven that aramang baked products enriched with malunggay was acceptable in terms of Odor, Taste, Flavor, Color, and Texture. Based on the results of sensory evaluation of enriched aramang baked products proven that three (3) treatments were all highly acceptable in terms of variable Odor, Taste, Flavor, Color and Textures conducted by the researchers.
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Semelhante a The Causes of Gastrointestinal Tract Perforation and its Management
An intestinal obstruction occurs when your small or large intestine is blocked. The blockage can be partial or total, and it prevents passage of fluids and digested food. If intestinal obstruction happens, food, fluids, gastric acids, and gas build up behind the site of the blockage.
Evaluation and management of intestinal obstructionImad Zoukar
This document discusses the evaluation and management of intestinal obstruction. Key points include:
- Intestinal obstruction is most commonly caused by adhesions, malignancy, or herniation and presents with abdominal pain, nausea/vomiting, and inability to pass gas/stool.
- Diagnostic testing includes abdominal x-rays, which show dilated bowel loops in 60% of cases, and CT scan, which is more sensitive and can identify the level and cause of obstruction.
- Management involves fluid resuscitation, bowel rest with nasogastric decompression, and surgery if there is evidence of vascular compromise, perforation, or failure to resolve with conservative measures.
Cysts of the mesentery are among surgical rarities and of varied aetiology with variable presentations and
this has surgical implications in the pediatric age group. They may be derived from the gastrointestinal
tract, the genitourinary system, previous inflammation (pseudocysts) or malignant cystic tumours, but the
commonest cause is generally considered to be a congenital lymphatic cyst. The clinical presentation is not
characteristic and in addition, the preoperative imaging although suggestive is not diagnostic. In most
cases, the diagnosis is confirmed after surgical exploration and removal of the cyst. A case report of a
baby aged 6 months is being reported. Hope that this information will reinforce the diagnostic and
treatment strategy
Lipoma of the Small Intestine: A Cause for Intussusception in AdultsKETAN VAGHOLKAR
This case report describes a rare case of small intestinal intussusception in a 22-year-old male patient caused by a lipoma. Imaging including ultrasound and CT scan revealed the classic signs of intussusception and identified a likely lipoma as the cause. During surgery, an ileoileocolic intussusception was found and gently reduced, finding a submucosal lipoma as the pathological lead point. The involved intestinal segment containing the lipoma was resected. Histopathological examination confirmed the diagnosis of benign submucosal lipoma. The patient recovered well with no further symptoms.
Bouveret's syndrome as an unusual cause of gastric outletFerstman Duran
This case report describes an 83-year-old man who presented with vomiting and abdominal pain and was found to have Bouveret's syndrome. Endoscopy revealed a large mass obstructing the duodenum, which was discovered to be a gallstone during surgery. The gallstone had caused a cholecysto-duodenal fistula. Initial surgery removed the fistula but the gallstone remained, requiring a second surgery to remove it from the duodenum. Bouveret's syndrome is a rare complication of gallstones that can cause gastric outlet obstruction.
Surgical Complications of Roundworm InfestationKETAN VAGHOLKAR
Round worm infestation is common in the tropical countries. Ascaris lumbricoides can cause a variety of complications in the abdomen ranging from colic to perforative peritonitis. As majority of abdominal complications require surgical intervention awareness of the complications is pivotal to the attending surgeon. The surgical complications of roundworm infestation are discussed in this article.
This document proposes a clinical algorithm for managing open abdomen with concomitant entero-atmospheric fistula (EAF), a surgical complication with high mortality. The algorithm aims to guide surgeons in choosing the best approach on a case-by-case basis. EAF is defined as an enteric fistula occurring within an open abdomen, lacking a tract and surrounding tissue. Current management techniques aim to divert fistula output, protect viscera, and allow bowel granulation. However, no single approach is ideal and significant heterogeneity exists. The document reviews various techniques and proposes a flowchart to help select the optimal individualized strategy. It also provides a detailed description of a "baby bottle nipple diversion" technique developed by the
Injuries to bowel and mesentery. Lecture pptxShashi Prakash
The document discusses traumatic injuries to the bowel and mesentery from blunt abdominal trauma. It notes that the bowel and mesentery are commonly injured structures after the liver and spleen. Delayed diagnosis of 8 hours or more of bowel and mesenteric injuries can result in severe complications like bleeding, peritonitis, and sepsis. CT scans are important for diagnosis as they can identify signs of intestinal perforation, bleeding, or vascular injuries that require immediate surgery. The most common sites of bowel injury are the small bowel, particularly the proximal jejunum and distal ileum. Colon injuries from blunt trauma are less common.
This document discusses acute intestinal obstruction, including classifications, causes, clinical features, investigations and treatments. It classifies obstruction based on origin, method of occurrence, blood flow and clinical course. Mechanical obstruction is distinguished from functional obstruction. Signs of small bowel obstruction include abdominal pain, nausea, vomiting and distention. Large bowel obstruction causes dull abdominal cramps and distention. Treatment involves decompression, fluid resuscitation, antibiotics and surgery to remove obstructions and non-viable bowel segments.
Laparoscopic Excision of Foregut Duplication Cyst of StomachApollo Hospitals
Retroperitoneal gastric duplication cysts lined by ciliated columnar epithelium are extremely rare lesions and its presentation during adulthood is a diagnostic challenge for treating clinicians. This entity often resembles cystic pancreatic neoplasm, retroperitoneal cystic lesions and sometimes as an adrenal cystic neoplasm. Correct diagnosis on the basis of radiological investigation is difficult and histopathologic analysis. We report a case of gastric duplication cyst in a 16year old girl that mimicked as a retroperitoneal /pancreatic /adrenal cystic lesion and was successfully managed by laparoscopy.
This document discusses a case of intestinal obstruction in a patient with a history of colon cancer. It provides background on the patient's symptoms and signs, including abdominal pain and distention, vomiting, and hemoccult-positive stool. The next steps are described as an abdominal series to determine the level and severity of obstruction. The pathophysiology of mechanical bowel obstruction is traced, involving distention, pain, potential ischemia and necrosis. Nursing management focuses on acute pain, risk for deficient fluid volume, risk for imbalanced nutrition, and ineffective tissue perfusion monitoring.
Case presentation volvulus in geriatric patientReynel Dan
1. The document presents a case of intestinal obstruction in a geriatric patient, discussing the etiology, pathophysiology, signs and symptoms, and nursing care for intestinal obstruction.
2. Intestinal obstruction can be caused by adhesions, hernias, tumors, or volvulus and results in a blockage of intestinal contents that increases pressure and risk of ischemia in the bowel.
3. Nursing care focuses on pain management, fluid resuscitation, monitoring for complications like peritonitis, and supportive care until the obstruction can be resolved medically or surgically.
Peritoneal carcinomatosis represents a devastating form of cancer progression with a very poor prognosis. Its complex pathogenesis is represented by a dynamic process comprising several steps. To the best of our knowledge pathogenesis can be partly explained by 3 major molecular pathways 1 dissemination from the primary tumor 2 primary tumor of peritoneum and 3 independent origins of the primary tumor and peritoneal implants. These are not mutually exclusive and combinations of different mechanisms could occur inside a single case. There are still several aspects which need explanation by future studies. A comprehensive understanding of molecular events involved in peritoneal carcinomatosis is of paramount importance and should be systematically pursued not only to identify novel strategies for the prevention of the condition, but also to obtain therapeutic advances, through the identification of surrogate markers of prognosis and development of future molecular targeted therapies. Mrs. Karpagam | Govinda Raj U "Peritoneal Carcinomatosis: A Case Report" Published in International Journal of Trend in Scientific Research and Development (ijtsrd), ISSN: 2456-6470, Volume-7 | Issue-4, August 2023, URL: https://www.ijtsrd.com/papers/ijtsrd59721.pdf Paper Url:https://www.ijtsrd.com/medicine/nursing/59721/peritoneal-carcinomatosis-a-case-report/mrs-karpagam
This document discusses colostomies, including reasons they may be needed such as cancer of the large intestine, perforated diverticulitis, Crohn's disease, and ulcerative colitis. It provides details on the anatomy and function of the digestive tract. The document is intended as an educational tool for healthcare professionals and discusses the physiological, surgical, practical, psychological, and social implications of living with a colostomy. It was created by Coloplast as part of their DialogueEducation materials and engagement with stoma nurses and patients.
Omental torsion: a rare cause of acute abdomenKETAN VAGHOLKAR
Torsion of the greater omentum is one of the rare causes of acute abdomen. However with an increase in the incidence of obesity in urban population there is a steady increase in the incidence of this rare and deceptive abdominal condition. The attending surgeon needs to be aware of this condition especially when confronted with an obese patient presenting as an acute abdomen. The paper reviews the etiopathogenesis and management of this rare condition.
This document discusses obstetrics and gynecology articles related to massive vaginal vault prolapse and enterocele. It provides definitions and descriptions of pelvic organ prolapse, including its causes, symptoms, diagnosis, and treatment. Pelvic organ prolapse is defined as the descent of the anterior vaginal wall, posterior vaginal wall, uterus, or vaginal vault. Causes can include childbirth injuries or surgery that damage pelvic floor muscles and nerves. Symptoms vary but may include a feeling of pressure or fullness in the pelvis. Diagnosis involves examination and sometimes tests like ultrasound or manometry. Treatment aims to regulate bowel movements and strengthen pelvic floor muscles through exercises or devices.
PowerPoint presentation on Choledochal Cysts, also known as biliary cyst, uploaded by Dr. Vaskar Humagain, first presented in 31st December, 2013. This presentation contains all the information about Choledochal Cysts, the original and revised Todani classification of choledochal cysts, pathogenesis, other associated congenital anomalies, clinical features in infant and adult, management of choledochal cysts. Comments are highly welcome :)
This document discusses postoperative complications that can occur after ulcerative colitis surgery involving an ileal pouch-anal anastomosis (IPAA). It describes several categories of complications, including surgical/mechanical issues like anastomotic leaks, pelvic sepsis, fistulae and strictures. It also discusses inflammatory disorders such as pouchitis, cuffitis and irritable pouch syndrome. Crohn's disease of the pouch is another possible complication, and the document provides criteria for differentiating this from backwash ileitis. Treatment options are mentioned for several of the complications.
Semelhante a The Causes of Gastrointestinal Tract Perforation and its Management (20)
Water sources and management practices among the household residents of Baran...Open Access Research Paper
The purpose of this study is to determine the water sources and management practices among the household residents of Barangay Labuyo, Tangub City, Misamis Occidental. A total of 204 household respondents were randomly interviewed using a survey questionnaire. Data on water management practices were measured using a 5-point Likert scale. One-way ANOVA and Pearson correlation were further used to determine the differences and relationships between demographic profiles and management practices. Results show that pipe water supply from the main source (68%) was the primary water source used among household residents. In terms of sex, females often practice water management on the water sources with a weighted mean of 3.42. While respondents with age 68 years and older exhibit a higher degree (weighted mean=3.63) of involvement in water conservation measures. And respondents with college degree have applied their in-depth comprehension and knowledge on water conservation with a weighted mean of 3.48. The study also revealed a significant difference in the management practices between two sexes, among all ages and levels of educational attainment with p values <0.05. The association between demographic profiles with management practices further presents a significant relationship. Generally, the demographic profile (sex, age, and educational attainment) has a weak positive relationship towards management practices with values, r = 0.26, p = 0.00021; r = 0.34, p = <0.05; and r = 0.26, p = 0.00014, respectively. Thus, results suggest the need for enhancing community awareness on sustainable water source management and putting it into practice consequently reducing inadequacy of water supply in the area.
The modification of an existing product or the formulation of a new product to fill a newly identified market niche or customer need are both examples of product development. This study generally developed and conducted the formulation of aramang baked products enriched with malunggay conducted by the researchers. Specifically, it answered the acceptability level in terms of taste, texture, flavor, odor, and color also the overall acceptability of enriched aramang baked products. The study used the frequency distribution for evaluators to determine the acceptability of enriched aramang baked products enriched with malunggay. As per sensory evaluation conducted by the researchers, it was proven that aramang baked products enriched with malunggay was acceptable in terms of Odor, Taste, Flavor, Color, and Texture. Based on the results of sensory evaluation of enriched aramang baked products proven that three (3) treatments were all highly acceptable in terms of variable Odor, Taste, Flavor, Color and Textures conducted by the researchers.
Microbiological assessment of air quality of selected locations within Verita...Open Access Research Paper
The study investigated the microbiological quality of indoor and outdoor air of certain locations – the chapel, basement, classroom, hostel, as well as the old and new microbiology laboratories in Veritas University, Abuja. The settle plate technique using open Petri dishes containing different culture media was employed to collect samples daily for 5 weeks at 7 days intervals. Standard microbiological methods were employed for the identification of bacterial and fungal isolates. The bacterial counts ranged from 1.90×106 to 5.3×106 and 2.90 x 106 to 6.20 x 106 for indoor and outdoor air while the fungal counts ranged from 2.30 x106 to 3.70 x 106 and 2.10 x 106 to 4.40 x 106 also for indoor and outdoor air respectively. The bacterial isolates were identified to include Bacillus species and Staphylococcus aureus with percentage occurrence of 44.0% and 56.0% respectively. The results obtained also showed the occurrence of three major fungal species namely Aspergillus sp (60.0%), Rhodotolura sp (5.0%), and Rhizopus sp (35.00%). The bacterial isolate, Staphylococcus aureus (56.0%) was shown to be the most predominant airborne bacteria while Aspergillus sp (60.0%) was the most frequently isolated fungal species. The 95% confidence level statistical analysis showed a significant difference between the indoor and outdoor air microbial load of the selected locations. Data generated underline the usefulness of monitoring the air quality of the selected locations because the contamination of indoor and outdoor habitats can cause health problems and even an increase in human mortality.
Kinetic studies on malachite green dye adsorption from aqueous solutions by A...Open Access Research Paper
Water polluted by dyestuffs compounds is a global threat to health and the environment; accordingly, we prepared a green novel sorbent chemical and Physical system from an algae, chitosan and chitosan nanoparticle and impregnated with algae with chitosan nanocomposite for the sorption of Malachite green dye from water. The algae with chitosan nanocomposite by a simple method and used as a recyclable and effective adsorbent for the removal of malachite green dye from aqueous solutions. Algae, chitosan, chitosan nanoparticle and algae with chitosan nanocomposite were characterized using different physicochemical methods. The functional groups and chemical compounds found in algae, chitosan, chitosan algae, chitosan nanoparticle, and chitosan nanoparticle with algae were identified using FTIR, SEM, and TGADTA/DTG techniques. The optimal adsorption conditions, different dosages, pH and Temperature the amount of algae with chitosan nanocomposite were determined. At optimized conditions and the batch equilibrium studies more than 99% of the dye was removed. The adsorption process data matched well kinetics showed that the reaction order for dye varied with pseudo-first order and pseudo-second order. Furthermore, the maximum adsorption capacity of the algae with chitosan nanocomposite toward malachite green dye reached as high as 15.5mg/g, respectively. Finally, multiple times reusing of algae with chitosan nanocomposite and removing dye from a real wastewater has made it a promising and attractive option for further practical applications.
Effects of Covid-19 pandemic on commodity price volatility and the welfare of...Open Access Research Paper
The evolving uncertainty of the emergence of the COVID-19 pandemic has adversely impacted some commodity prices, the welfare of farming households, and the economic growth and development of the country. The study is aimed at assessing the effects of Covid -19 pandemic on commodity price volatility and the welfare of farming households in Nigeria. The study was based on secondary data from (2010- 2022, and forecasts from 2023 -2026), collected from the Central Bank of Nigeria publication, IMF World economic outlook, and the World Bank report. Time- response graph and Autoregressive Moving Average (ARMA) was used to analyze the trend of the inflation rate, and T-test statistics, were used to test the relationship between the real income of farming household before and during the pandemic. The result showed that prices of some commodities doubled after the pandemic. There is a significant difference between the real income of farming households before and during the pandemic. The study recommends that a price control mechanism should be put in place to manage the affordability of goods and services in the market because this has a direct effect on the growth and development of the country.
Effect of foliar application of water soluble fertilizer on growth, yield and...Open Access Research Paper
The tomato is the one of the most famous crops in Pakistan. It is used and consumed as fresh as well as in processed form. Its botanical name is Solanum lycopersicon Mill. The proposed study had been conducted in the year 2017-2018 in order to find the best combination of water soluble NPK fertilizers as compared to control. Five different types of water soluble fertilizers were collected from different sources and were applied at 5% concentration during the entire growing period of the tomato crop. The experiment was designed using Randomized Complete Block Design (RCBD) with five treatments and three replications of each. Different vegetative, reproductive and bio-chemical parameters were recorded and analyzed statistically at 5% level of significance. The treatments were compared using LSD test. It was concluded that different NPK water soluble fertilizers showed variation in physical and bio chemical parameters in tomato plants as compared to control. The plants showed variation in plant height, No. of fruit per plant, fruit yield per hectare, Individual fruit weight, fruit weight per plant, No. of diseased fruit per plant, date of first harvest, Fruit color Fruit length (cm), fruit size (cm), fruit firmness, total NPK contents, vitamincmg Chlorophyll concentration, pH, (TSS), Electricity conductivity (EC) and Titratable acidity Among all the water soluble treatments, the T3 treatment (WSF 20:20:20) yielded the comparatively better results as compared to other WSF treatments. So it was concluded that T3 was the recommended water soluble fertilizer for tomato.
Yield response of aman rice to transplanting geometry and seedlings per hill ...Open Access Research Paper
In a condition of limited scope of horizontal yield expansion, rice yield can be increased by efficient utilization of land through proper transplanting arrangement with maximum number of plant population unit-1 area. Thus, the present experiment was conducted in the farmer’s field at Batiaghata upazila of Khulna district, Bangladesh during T. aman season (Jul-Nov) to evaluate the effect of transplanting geometry and number of seedlings hill-1 on growth and yield of aman rice (Binadhan-7, a short duration variety of its’ early harvest can create opportunity to cultivate winter crops in this region). The experiment had four types of transplanting geometry (single row rectangular system, single row triangular system, double row rectangular system and double row triangular system) and three levels of seedling hill-1 (3, 4 and 5 seedlings) with three replications. The results showed that individually transplanting geometry or number of seedlings hill-1 had substantial influence on yield attributes and yield but their interaction effect had non-significant influence on almost all measured parameters except number of tillers and effective tillers hill-1. The maximum grain yield (5.6 t ha-1) was achieved from double row triangular system yet the highest plant height, effective tillers hill-1, grain panicle-1, 1000 grain weight and straw yield were obtained from single row triangular system. In case of seeding hill-1, 3 seedlings hill-1 produced the highest grain yield (5.33 t ha-1) plant height, effective tillers hill-1, grain panicle-1, 1000 grain weight and straw yield. It can be concluded that double row transplanting geometry with 3 seedlings hill-1 can utilize the land efficiently for grain yield and be recommended for cultivation of Binadhan-7 in the coastal region of south-western Bangladesh.
Evaluation of lead and arsenic content of Azardirachta indica seed oil and Ci...Open Access Research Paper
There is an increase preference for plant-based repellents due to their effectiveness, environmentally friendliness and biodegradable nature. It is therefore necessary to ascertain the safety of these repellents by analysing their heavy metal content. This study has shown that lead and arsenic content of Azadirachta indica seed oil cream and Citrus sinensis peel oil cream as mosquito repellent is insignificant and therefore very safe for use according to the Ghana Standard Authority specification. These results provide new insight into the safety of these natural mosquito repellents.
Determination of hydroxy methyl furfural concentration in honey using ultra v...Open Access Research Paper
This paper aimed to determine the concentration of hydroxyl methyl furfural (HMF) using UV-visible spectroscopy to assess the quality of honey. The honey samples were collected from three honeys productive temperature zones: temperate, sub-tropical and tropical. Following the procedure of white method, the concentration of HMF of temperate, sub-tropical and tropical zone honey are found to be 11.18 ± 0.052mg/kg, 24.95± 0.119mg/kg, and 56.94±0.366mg/kg respectively. There is statistically significance differences between the groups in HMF concentration at 95% confidence level (p<0.05). All the samples are found to have HMF value less than the maximum concentration of HMF in honey set by standard controlling international organizations, which shows good quality of the honey in the study areas.
Improving the viability of probiotics by encapsulation methods for developmen...Open Access Research Paper
The popularity of functional foods among scientists and common people has been increasing day by day. Awareness and modernization make the consumer think better regarding food and nutrition. Now a day’s individual knows very well about the relation between food consumption and disease prevalence. Humans have a diversity of microbes in the gut that together form the gut microflora. Probiotics are the health-promoting live microbial cells improve host health through gut and brain connection and fighting against harmful bacteria. Bifidobacterium and Lactobacillus are the two bacterial genera which are considered to be probiotic. These good bacteria are facing challenges of viability. There are so many factors such as sensitivity to heat, pH, acidity, osmotic effect, mechanical shear, chemical components, freezing and storage time as well which affects the viability of probiotics in the dairy food matrix as well as in the gut. Multiple efforts have been done in the past and ongoing in present for these beneficial microbial population stability until their destination in the gut. One of a useful technique known as microencapsulation makes the probiotic effective in the diversified conditions and maintain these microbe’s community to the optimum level for achieving targeted benefits. Dairy products are found to be an ideal vehicle for probiotic incorporation. It has been seen that the encapsulated microbial cells show higher viability than the free cells in different processing and storage conditions as well as against bile salts in the gut. They make the food functional when incorporated, without affecting the product sensory characteristics.
Microbial characterisation and identification, and potability of River Kuywa ...Open Access Research Paper
Water contamination is one of the major causes of water borne diseases worldwide. In Kenya, approximately 43% of people lack access to potable water due to human contamination. River Kuywa water is currently experiencing contamination due to human activities. Its water is widely used for domestic, agricultural, industrial and recreational purposes. This study aimed at characterizing bacteria and fungi in river Kuywa water. Water samples were randomly collected from four sites of the river: site A (Matisi), site B (Ngwelo), site C (Nzoia water pump) and site D (Chalicha), during the dry season (January-March 2018) and wet season (April-July 2018) and were transported to Maseno University Microbiology and plant pathology laboratory for analysis. The characterization and identification of bacteria and fungi were carried out using standard microbiological techniques. Nine bacterial genera and three fungi were identified from Kuywa river water. Clostridium spp., Staphylococcus spp., Enterobacter spp., Streptococcus spp., E. coli, Klebsiella spp., Shigella spp., Proteus spp. and Salmonella spp. Fungi were Fusarium oxysporum, Aspergillus flavus complex and Penicillium species. Wet season recorded highest bacterial and fungal counts (6.61-7.66 and 3.83-6.75cfu/ml) respectively. The results indicated that the river Kuywa water is polluted and therefore unsafe for human consumption before treatment. It is therefore recommended that the communities to ensure that they boil water especially for drinking.
High histological grade breast cancer morphological evaluation on mammogram u...Open Access Research Paper
To evaluate the high-grade breast cancer morphological complexity on mammogram. We conducted a retrospective study using an open source data got from figshare repository. These anonymized data were collected and used for a study approved by the institutional review board. Cranio-Caudal and Medio-lateral mammograms and their tumor segmented images from 66 patients subdivided in two groups high histological grade (n=23) low-grade (low and intermediate, n=41). From breast cancer image segmentation, we extracted fractal dimension using Fraclac, plugin of ImageJ software based on box-counting method. For our analysis we used comparatively the fractal dimension from cranio-caudal (CC) and medio-lateral (MLO) images. We summarized the fractal dimension of our cohort using boxplot and performed the Wilcoxon non-parametric statistic for fractal dimension comparison of two groups (High-grade and low-grade). There was not difference between CC (mean ± std= 1.1583±0.067) andmLO (mean ± std =1.1551±0.055) breast cancer fractal dimension. For the high-grade differentiation, CC andmLO images fractal dimension were contributed respectively at a little difference but without statistically difference (P value=0.438 and 0.435). High-grade fractal dimensions mean were respectively 1.142±0.044 and 1.144±0.075 for CC andmLO images against 1.166±0.050 and 1.160±0.057 for low-grade. It had been recorded a lower mean value of fractal dimension for high-grade breast cancer without statistically significant. This finding shows that the high-grade breast cancer tends to have a regular shape.
Characterization of inflammatory syndrome in smokers, from C-Reactive protein...Open Access Research Paper
A local inflammatory syndrome is characterized by a classic semiological tetrad: pain, swelling, redness and heat. These signs are easily observed when the inflammation concerns the skin or an adjacent tissue. Throughout this study, the aim was to characterize chronic inflammation in smokers using two parameters, rate of erythrocytes sedimentation (RES) and C – reactive protein (CRP). Our study was done on a sample of 35 smoking subjects, composed of men and women. The CRP measurement o was carried out using a CRP-Latex agglutination test which detects only serum CRP levels around 6mg/L. The technique used for the RES measurement is that of Westergreen. From the results, we observed that 31% of our sample presented a positive CRP and a high RES against 40% having regular CRP and RES. The gender of the subject did not play a role in the results obtained. On the other hand, a significant difference (p = 0.031) in CRP was observed between subjects with normal RES and those with high RES. Therefore, these results make it difficult to confirm that RES and CRP can be used as reliable markers for the characterization of inflammation linked to smoking.
Prevalence of diarrhea among severely malnourished children admitted in Gover...Open Access Research Paper
Mortality rate of children under the age of five has reduced worldwide, but still the probability of a child dying before the age of five is greatest in underdeveloped countries. Pakistan reports child mortality rates in same bracket as other South Asian countries due to malnutrition and diarrhea. To determine the prevalence and factors associated in children less than five years of age a cross sectional study was conducted with mothers whose children were admitted in pediatric government Hospital, Lahore. A convenient sample of 101 children (6-59 months, 53 males and 48 females) suffering from malnutrition and diarrhea were selected from hospital. Data about socio demographic, anthropometric, clinical and dietary variables were collected and analyzed by using SPSS version 16. The results showed that mean age of patients was 19.36 ± 10.5 months. The illiteracy rate among mother and father of patients was 94.1% and 69.3% respectively. 94.1% of the patients were breastfed while 47.5% of the patients were on bottle feed with breast milk. 66.3% patients families has very low-income rate while 33.7% were satisfactory. 40.6% patients were not vaccinated against immunization. Out of 101 patients, 39.6% of the patients had diarrhea while 6.9% of the patients had chronic diarrhea. The prevalence rate of diarrhea (39%) was less among children who were younger than 18 months as compared to those who were above 18 months (40.5%). The most significant factors that caused the incidence of diarrhea in children was form of water storage system, complementary feeding practices, and hand wash cleaning materials. This study concluded that government, nongovernmental organizations and families living with children and mothers could cooperate on strategies to minimize the risks of the diarrhea among children less than five years of age.
Accuracy of cervico vaginal fetal fibronectin test in predicting risk of spon...Open Access Research Paper
Preterm delivery is the leading cause of neonatal mortality. One of the best predictors to assess the risk of preterm labour (PTB) is by measuring fetal fibronectin (fFN) in cervico vaginal secretion after 26 weeks of pregnancy. The aim is to evaluate the diagnostic accuracy of qualitative cervico vaginal fFN in symptomatic women and asymptomatic high risk women during antenatal care. Prospective study which was conducted in Basrah Maternity and Child Hospital. It included 106 pregnant women at gestational age more than 26 weeks who had uterine contraction with or without pervious risk factors for PTB. Cervico vaginal fluid sampling was undertaken from all women included in the study after the age of 26 weeks of gestation and qualitative fFN assessment was done with 50ng/ml is the cut off point for positivity. As regard qualitative fFN assessment for predicting of PTB sensitivity, specificity, PPV, NPV, were 71%, 87%, 40.50%, 94% respectively in symptomatic women. While in asymptomatic women with previous high risk had 26% sensitivity, 84% specificity, 32% PPV, and 87% NPV. Qualitative assessment of fFN in cervico vaginal fluid is good predictive marker in detecting of PTB.
Characterization and the Kinetics of drying at the drying oven and with micro...Open Access Research Paper
The objective of this work is to contribute to valorization de Nephelium lappaceum by the characterization of kinetics of drying of seeds of Nephelium lappaceum. The seeds were dehydrated until a constant mass respectively in a drying oven and a microwawe oven. The temperatures and the powers of drying are respectively: 50, 60 and 70°C and 140, 280 and 420 W. The results show that the curves of drying of seeds of Nephelium lappaceum do not present a phase of constant kinetics. The coefficients of diffusion vary between 2.09.10-8 to 2.98. 10-8m-2/s in the interval of 50°C at 70°C and between 4.83×10-07 at 9.04×10-07 m-8/s for the powers going of 140 W with 420 W the relation between Arrhenius and a value of energy of activation of 16.49 kJ. mol-1 expressed the effect of the temperature on effective diffusivity.
According to WHO, Drug utilization research is defined as ‘the marketing, distribution, recommendation and utilize of drugs in a society, with particular focus on the resulting medical, social and economic results. In many developed countries, a number of studies about utilization of drug have been conducted, which indicates a wide proof of irrational drug use. The drug use indicators are considered as objective measures that can be extended to identify practices of medicines utilization in any health facility, country or an entire region. To check the drug utilize pattern in Primary Health Care (PHC) facilities of Bhakkar district Punjab Pakistan. Using WHO core drug use indicators, a prospective cross-sectional descriptive study was carried out in health facilities of Bhakkar district. A total of 40 prescriptions were analyzed. The average age of patients visiting HC centers was 33.11 years (female 35.79; male 30.40). 3.65 was the average number of prescribed drugs. 27% was the percentage of encounters with at least one prescribed antibiotic whereas 35% was the percentage of encounters with at least one prescribed injection prescribed, which was low. 25% is the total percentage of drugs given using generic names was noticed. The average consultation and dispensing time of 40 prescriptions was 2.02 minutes and 42.52 seconds. The study demonstrates that trend toward irrational practice mainly on use of antibiotics and non-generic prescribing in most of health facilities studied. Patient care given by health facilities studied was inadequate and thus for encouragement of rational drug use practice, an effective intervention program is recommended.
Diabetes is a significant cause of mortality and morbidity in different continents of the world. Many diabetes victims are found in developing countries like Sub-Saharan Africa. However, some developed nations like United States and Europe record significant records on diabetes prevalence. Studies project a dramatic increase of the infection spread in the world. Also, it provides visible results on the effects of the infection among the victims and the society at large. Studies of type 2 diabetes prevalence indicate minimal rates in rural population and moderate results in the developed regions of the same country. Such results create an alarm to the unaffected regions. The frequent observation of modestly high prevalence of impaired glucose tolerance in areas with low prevalence of diabetes indicate risk of early stage of diabetes epidemics.
Prevalence of Toxoplasma gondii infection in domestic animals in District Ban...Open Access Research Paper
Toxoplasma gondii is an intracellular zoonotic protozoan parasite, infect both humans and animals population worldwide. It can also cause abortion and inborn disease in humans and livestock population. In the present study total of 313 domestic animals were screened for Toxoplasma gondii infection. Of which 45 cows, 55 buffalos, 68 goats, 60 sheep and 85 shaver chicken were tested. Among these 40 (88.88%) cows were negative and 05 (11.12%) were positive. Similarly 55 (92.72%) buffalos were negative and 04 (07.28%) were positive. In goats 68 (98.52%) were negative and 01 (01.48%) was recorded positive. In sheep and shaver chicken the infection were not recorded.
Antimicrobial susceptibility pattern of Staphylococcus aureus, and their nasa...Open Access Research Paper
The frequency of Staphylococcus aureus carriage among healthy food handlers at the students’ cafeteria at the Federal University of Technology, Owerri Nigeria was investigated. Nasal and throat swab samples were obtained from 54 food handlers, and analysed using standard microbiological methods. A total of 28 (51.9%) food handlers were positive for S. aureus. Twenty one of the food handlers (38.9%) harbor S. aureus in their nostrils, 11 (20.4%) in their throat, while 6(11.1%) harbor it in both their nostrils and throats. The exclusive colonization of the throat (20.4%) of the studied food handlers, demonstrated the importance of the throat as a site of colonization for S. aureus. Antimicrobial susceptibility of isolates shows that all the isolated S. aureus were susceptible to nitrofurantoin and cefuroxime, but resistant to penicillin, chloramphenicol, cotrimazole. The isolates were also 25%, 28.6% and 35.7% susceptible to ampicillin, amoxycillin and erythromycin, respectively. This study has further shown the need for routine regular screening of food handlers for both nasal and throat carriage of S. aureus so as to detect early and treat carriers in order to protect the general public from staphylococcal food poisoning. The high prevalence of antimicrobial resistance in S. aureus isolated from the healthy food handlers is of great public health concern, as it shows a growing problem of antimicrobial resistance in the community. This study thus, recommends an urgent formulation of a national policy on antibiotics by the Nigerian government for regulation and management of antibiotics use.
How to Add Chatter in the odoo 17 ERP ModuleCeline George
In Odoo, the chatter is like a chat tool that helps you work together on records. You can leave notes and track things, making it easier to talk with your team and partners. Inside chatter, all communication history, activity, and changes will be displayed.
it describes the bony anatomy including the femoral head , acetabulum, labrum . also discusses the capsule , ligaments . muscle that act on the hip joint and the range of motion are outlined. factors affecting hip joint stability and weight transmission through the joint are summarized.
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Strategies for Effective Upskilling is a presentation by Chinwendu Peace in a Your Skill Boost Masterclass organisation by the Excellence Foundation for South Sudan on 08th and 09th June 2024 from 1 PM to 3 PM on each day.
How to Build a Module in Odoo 17 Using the Scaffold MethodCeline George
Odoo provides an option for creating a module by using a single line command. By using this command the user can make a whole structure of a module. It is very easy for a beginner to make a module. There is no need to make each file manually. This slide will show how to create a module using the scaffold method.
Walmart Business+ and Spark Good for Nonprofits.pdfTechSoup
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The webinar may also give some examples on how nonprofits can best leverage Walmart Business+.
The event will cover the following::
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Spark Good (walmart.com/sparkgood) is a charitable platform that enables nonprofits to receive donations directly from customers and associates.
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How to Make a Field Mandatory in Odoo 17Celine George
In Odoo, making a field required can be done through both Python code and XML views. When you set the required attribute to True in Python code, it makes the field required across all views where it's used. Conversely, when you set the required attribute in XML views, it makes the field required only in the context of that particular view.
This presentation includes basic of PCOS their pathology and treatment and also Ayurveda correlation of PCOS and Ayurvedic line of treatment mentioned in classics.
The Causes of Gastrointestinal Tract Perforation and its Management
1. 91 Urooj et al.
Int. J. Biosci. 2022
RESEARCH PAPER OPEN ACCESS
The Causes of Gastrointestinal Tract Perforation and its
Management
Bakhtawar Urooj1
, Nadia Mehreen2
, Munazza Laraibe1
, Zarak Khan1
, Zohra
Samreen3
, Bushra Aziz4
, Beenish Mahjabeen5
, Nargis Taj4
, Ghazala Taj4
, Muhammad
Kamran Taj6*
1
Department of Surgery, Sandeman Provincial Hospital Quetta, Balochistan
2
Department of Gynae, Sandeman Provincial Hospital Quetta, Balochistan
3
Department of Dermatology, Sandeman Provincial Hospital Quetta, Balochistan
4
Bolan Medical Hospital Quetta, Balochistan
5
Helper Eye Hospital Quetta, Balochistan
6
CASVAB, University of Balochistan
Key words: Ileal, Perforation, Fever, Skin, Excoriation.
http://dx.doi.org/10.12692/ijb/20.1.91-115 Article published on January 04, 2022
Abstract
Perforation of the gastrointestinal tract may be suspected based upon the patient's clinical presentation, or the
diagnosis becomes obvious through a report of extra luminal "free" gas or fluid or fluid collection on diagnostic
imaging performed to evaluate abdominal pain or another symptom. Clinical manifestations depend somewhat
on the organ affected and the nature of the contents released (gas, succus entericus, stool), as well as the ability of
the surrounding tissues to contain those contents. Intestinal perforation can present acutely or in an indolent
manner (e.g., abscess or intestinal fistula formation). A confirmatory diagnosis is made primarily using abdominal
imaging studies, but on occasion, exploration of the abdomen (open or laparoscopic) may be needed to make a
diagnosis. Specific treatment depends upon the nature of the disease process that caused the perforation. Some
etiologies are amenable toa nonoperative approach, while others will require emergent surgery.
* Corresponding Author: Muhammad Kamran Taj kamrancasvab@yahoo.com
International Journal of Biosciences | IJB |
ISSN: 2220-6655 (Print), 2222-5234 (Online)
http://www.innspub.net
Vol. 20, No. 1, p. 91-115, 2022
2. 92 Urooj et al.
Int. J. Biosci. 2022
Introduction
Perforation requires full-thickness injury of the bowel
wall; however, partial-thickness bowel injury (e.g.,
electrocautery, blunt trauma) can progress over time
to become a full-thickness injury or perforation,
subsequently releasing gastrointestinal contents. Full-
thickness injury and subsequent perforation of the
gastrointestinal tract can be due to a variety of
etiologies, commonly instrumentation (particularly
with cautery) or surgery, blunt or penetrating injury,
and bowel obstruction. In addition to causing
obstruction, neoplasms (particularly colon
carcinoma) can also cause perforation by direct
penetration of the tumor through the bowel wall.
Other etiologies are less common (Khalid et al.,
2014). Spontaneous perforation can be related to
inflammatory changes or tissues weakened by
medications or connective tissue disorders.
Esophageal, gastric, or duodenal perforations may
also be associated with peptic ulcer disease, corrosive
agents, or particularmedications (Wain et al., 2015).
With bowel obstruction, perforation occurs proximal
to the obstruction as pressure builds up within the
bowel, exceeding intestinal perfusion pressure and
leading to ischemia and subsequently necrosis. When
perforation is proximal to a colon obstruction, it
usually occurs in the cecum in the presence of a
competent ileocecal valve. Enteroliths and gallstones
can also cause perforation by direct pressure or
indirectly by leading to obstruction resulting in a
proximal perforation (Eligijus Poskus et al., 2014;
Jain et al., 2016). Alternatively, the excess pressure
can cause the musculature of the bowel to fail
mechanically; in other words, to simply split
(diastatic rupture) without any obvious necrosis.
Intestinal pseudo-obstruction can also lead to
perforation by these mechanisms (Lob et al., 2018).
As free gas accumulates in the peritoneal cavity, it can
compress intra- abdominal veins or lead to
respiratory insufficiency by compromising
diaphragmatic function (Agu et al., 2014). Such a
tension pneumoperitoneum (valvular
pneumoperitoneum) can result from iatrogenic or
pathologic processes. Perforation and subsequent
inflammation can also cause abdominal compartment
syndrome (Akinwale et al., 2016).
Anatomic considerations
Knowledge of gastrointestinal anatomy and anatomic
relationships to adjacent organs helps predict
symptoms and to interpret imaging studies in patients
with a possible gastrointestinal perforation. Whether
or not gastrointestinal perforation leads to free fluid
and diffuse peritonitis or is contained, resulting in an
abscess or fistula formation, depends upon the
location along the gastrointestinal tract and the
patient's ability tomount an inflammatory response to
the specific pathologic process (Singh et al., 2008). As
an example, retroperitoneal perforations are more
likely to be contained. Immunosuppressive and anti-
inflammatory medications impair this response. In
brief, the relationship of the gastrointestinal tract to
itself and other structures is as follows: The
esophagus begins in the neck and descends adjacent
to the aorta through the esophageal hiatus to the
gastroesophageal junction. Perforations of the
esophagus due to foreign body ingestion usually occur
at the narrow areas of the esophagus, such as the
cricopharyngeus muscle, aortic arch, left main stem
bronchus, and lower esophageal sphincter. The
stomach is located in the left upper quadrant of the
abdomen but can occupy other areas of the abdomen,
depending upon its degree of distention, phase of
diaphragmatic excursion, and the position of the
individual. Anteriorly, the stomach is adjacent to the
left lobe of the liver, diaphragm, colon, and anterior
abdominal wall. Posteriorly, the stomach is near the
pancreas, spleen, left kidney and adrenal gland,
splenic artery, left diaphragm, transverse mesocolon,
and colon (Patel et al., 2010).
The esophagus has three anatomical points of
narrowing that are prone to perforation. These sites
include the cricopharyngeus muscle, the broncho-
aortic constriction, and the esophagogastric junction.
The esophagogastric junction is the most common
site of perforation. The relationship of the stomach to
surrounding structures is depicted in the figure. The
arterial supply to the stomach is derived primarily
from the celiac axis. The celiac axis arises from the
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proximal abdominal aorta and typically branches into
the common hepatic, splenic, and left gastric arteries.
The common hepatic artery usually gives rise to the
gastroduodenal artery (in approximately 75 percent of
people), which, in turn, branches off into the right
gastroepiploic artery and the anterior and posterior
superior pancreaticoduodenal arteries, which supply
the pancreas. The right gastroepiploic artery joins
with the left gastroepiploic artery, which emanates
from the splenic artery in 90 percent of patients. The
right gastric artery branches from the hepatic artery
and anastomoses with the left gastric artery along the
lesser curvature of the stomach. The small bowel is
anatomically divided into three portions: the
duodenum, jejunum, and ileum. The duodenum is
retroperitoneal in its second and third portions and
forms a loop around the head of the pancreas. The
jejunum is in continuity with the fourth portion of the
duodenum beginning at the ligament of Treitz; there
are no true lines of demarcation that separate the
jejunum from the ileum. The ileocecal valve marks
the beginning of the colon in the right lower
quadrant. The appendix hangs freely from the cecum,
which is the first portion of the colon. Foreign bodies
that perforate the small intestines most commonly
occur at sites of gastrointestinal immobility (e.g.,
duodenum). The ascending and descending colon are
retroperitoneal, while the transverse colon, which
extends from the hepatic flexure to the splenic
flexure, is intraperitoneal. The sigmoid colon
continues from the descending colon, ending where
the tinea coli converge to form the rectum. The
anterior upper two-thirds of the rectum is located
intra peritoneally and the remainder is
extraperitoneal. The rectum lies anterior to the three
inferior sacral vertebrae, coccyx, and sacral vessels and
is posterior to the bladder in men and the vagina in
women. Foreign bodies that perforate the colon tend
to occur at transition zones from an intraperitoneal
location to fixed retroperitoneal locations such as the
cecum (Robles-Medranda et al., 2008).
Risk factors of perforation
Factors that increase the risk for gastrointestinal
perforation are discussed below and are important to
assess when taking the history of any patient
suspected of having gastrointestinal perforation
(Browning et al., 2007).
Instrumentation/surgery
Instrumentation of the gastrointestinal tract is the
main cause of iatrogenic perforation and may include
upper endoscopy (especially rigid endoscopy),
sigmoidoscopy, colonoscopy (Souadka et al., 2012;
Nassour and Fang, 2015) stent placement, endoscopic
sclerotherapy (Schmitz et al., 2001) nasogastric
intubation (Ghahremani et al., 1980) esophageal
dilation, and surgery. The incidence of perforation
related to endoscopy increases with procedural
complexity. Perforation is less common with
diagnostic compared with therapeutic procedures
(Isomoto et al., 2009) A perforation rate of 0.11
percent for rigid endoscopy contrasts with a 0.03
percent rate for flexible endoscopy (Kavic et al.,
2001). When iatrogenic perforation occurs, there is
often significantly associated pathology. As an
example, in the esophagus, there may be stricture,
severe esophagitis (Eisenbach et al., 2006) or a
diverticulum, and the presence of cervical osteophytes
also increases the risk (Silvis et al., 1976). The area of
the esophagus at most risk for instrumental
perforation is Killian's triangle (Brinster et al., 2004),
which is the part of the pharynx formed by the
inferior pharyngeal constrictor and cricopharyngeus
muscle. During endoscopy, perforations are
frequently recognized at the time of the procedure. At
other times, the perforation remains occult for several
days.
When the normal anatomy of the esophagus or
stomach has been disturbed, such as after Roux-en-Y
gastric bypass, great care should be taken with
nasogastric intubation (Lortie and Charbonney,
2016). Other procedures can also be complicated with
perforation, such as chest tube insertion low in the
chest (Andrabi et al., 2007), peritoneal dialysis
catheter insertion, percutaneous gastrostomy
(Covarrubias et al., 2013), paracentesis, diagnostic
peritoneal lavage, and percutaneous drainage of fluid
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collections or abscess. With surgery, perforation can
occur during initial laparoscopic access, during
mobilization of the organs or during the takedown of
adhesions, or as a result of thermal injury from
electrocautery devices (Turrentine et al., 2015).
Gastrointestinal leakage can also occur
postoperatively as a result of an anastomotic
breakdown. Immunosuppressed individuals may be
at increased risk for dehiscence and deep organ space
infection following surgery. Medical illnesses such as
diabetes, cirrhosis, and HIV are associated with an
increased risk of anastomotic leak after colon
resection for trauma (Stewart et al., 1994).
Penetrating or blunt trauma
Traumatic perforation of the gastrointestinal tract is
most likely a result of penetrating injury, although
blunt perforation can occur with severe abdominal
trauma acutely related to pressure effects or as a
portion of the gastrointestinal tract is compressed
against a fixed bony structure, or more slowly as a
contusion develops into a full-thickness injury (Lortie
and Charbonney, 2016).
Medications, other ingestions, foreign body
Medications or other ingested substances (caustic
injury) and foreign bodies (ingested or medical
devices) can lead to gastrointestinal perforation.
Foreignbodies, suchas sharp objects (toothpicks),food
with sharp surfaces (e.g., chicken bones, fish), or
gastric bezoar more commonly cause perforation,
compared with dislodged medical implants (Shimizu
et al., 2010; Oestreich, 2009). Button batteries as an
esophageal foreign body have a more pronounced
perforation risk (Peters et al., 2015). Surgically
implanted foreign bodies such as hernia mesh (Ott et
al., 2005) and artificial vascular grafts (Fujihara et
al., 2013) can cause perforation with subsequent
abscess and fistula formation or vasculoenteric
fistulas. Aspirin and nonsteroidal anti-inflammatory
drug (NSAID) use has been associated with
perforation of the stomach and duodenum with
diclofenac and ibuprofen being the most commonly
implicated drugs (Morris et al., 2003). Some disease-
modifying antirheumatic drugs (DMARDs) have been
associated with lower intestinal perforations
(Strangfeld et al., 2017). Rarely NSAIDs have
produced jejunal perforations (Risty et al., 2007).
Glucocorticoids, particularly in association with
NSAIDs, are particularly problematic (Aloysius et al.,
2006). Further, because steroids suppress the
inflammatory response, detection of perforation can
be delayed. NSAIDs, antibiotics, and potassium
supplements are also common causative medications
for pill-induced esophageal ulcers (Abid et al., 2005).
Othermedication-induced injury leading to
perforation has been reported for
immunosuppressive therapies, cancer chemotherapy
in patients with metastases, and for iron
supplementation causing esophageal injury (Corsi et
al., 2006 ).
Violent retching/vomiting
Violent retching/vomiting can lead to spontaneous
esophageal perforation, known as Boerhaave
syndrome. This occurs because of failure of the
cricopharyngeal muscle to relax during vomiting or
retching causing increased intraesophageal pressure
in the loweresophagus (Wu et al., 2007).
Hernia/intestinal volvulus/obstruction
Abdominal wall, groin, diaphragmatic, internal
hernia, paraesophageal hernia, and volvulus (gastric,
cecal, sigmoid) can all lead to perforation either
related to bowel wall ischemia from strangulation, or
pressure necrosis. Perforation can also occur with
afferent loop obstruction after Roux-en-Y
reconstruction. Crohn's disease has a propensity to
perforate slowly, leading to the formation of entero-
enteric or enterocutaneous fistula formation (Simillis
et al., 2008).
A portion of appendicitis results in perforation, which
can lead to life-threatening complications if left
untreated, including intra-abdominal infection,
sepsis, intraperitoneal abscesses, and, rarely, death
(Parks and Schroeppel, 2011). In adults, the risk of
perforated appendicitis increases with the male
gender, increasing age and comorbidity, and lack of
medical insurance coverage (Drake et al., 2013).
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Peptic ulcer disease
Peptic ulcer disease (PUD) is the most common cause
of stomach and duodenal perforation but occurs in a
small percentage of patients with PUD (Behrman,
2005). In spite of the introduction of proton pump
inhibitors, the incidence of perforation from PUD has
not changed appreciably (Hermansson et al., 2009).
Marginal ulceration leading to perforation may also
complicate surgeries that create a gastrojejunostomy
(e.g., partial gastric resection, bariatric surgery.
Diverticular disease
Colonic diverticulosis is common in the developed
world. All clinical cases ofdiverticulitis represent some
degree of perforation of the thinned diverticular wall,
leading to inflammation of the adjacent parietal
peritoneum (West, 2008). Perforation can also occur
with duodenal or small intestinal diverticula (jejunal,
Meckel's). These diverticula can become inflamed,
much as in colonic diverticulitis, and perforate, which
may lead to abscess formation.
Cardiovascular disease
Any process that reduces the blood flow to the
intestines (occlusive or nonocclusive mesenteric
ischemia) for an extended period of time increases the
risk for perforation, including embolism, mesenteric
occlusive disease, cardiopulmonary resuscitation, and
heart failure that leads to gastrointestinal ischemia
(Spoormans et al., 2010).
Infectious disease
Typhoid, tuberculosis, and schistosomiasis can cause
perforation of the small intestine (Tan et al., 2009).
With typhoid, the perforation is usually in a single
location (ileum at necrotic Peyer's patches), but it can
be multiple. Typhoid perforation is more common in
children, adolescents, or young adults.
Cytomegalovirus, particularly in an
immunosuppressed patient, can cause intestinal
perforation.
Neoplasms
Neoplasms can perforate by direct penetration and
necrosis or by producing obstruction. Perforations
related to the tumor can also occur spontaneously,
following chemotherapy, or as a result of radiation
treatments when the tumor involves the wall of a
hollow viscus organ (Kang et al., 2010). Delayed
perforations of the esophagus or duodenum in
patients with malignancy can be related to stent
placement for malignantobstruction.
Connective tissue disease
Spontaneous perforation of the small intestine or
colon has been reported in patients with underlying
connective tissue diseases (e.g., Ehlers-Danlos
syndrome), collagen vascular disease, and
vasculitis(Nakashima et al., 2006). This entity occurs
in the neonate or premature infants. No
demonstrable cause is appreciated (Farrugia et al.,
2003).
Clinical features of perforation
A careful history is important in evaluating patients
with neck, chest, and abdominal pain. The history
should include questioning about prior bouts of
abdominal or chest pain, prior instrumentation
(nasogastric tube, abdominal trauma, endoscopy),
prior surgery, malignancy, possible ingested foreign
bodies (e.g., fish or chicken bone ingestion), and
medical conditions (e.g., peptic disease, medical
device implants), including medications (nonsteroidal
anti-inflammatory drugs [NSAIDs], glucocorticoids)
that predispose to gastrointestinal perforation.
Patients with perforation may complain of the chest
or abdominal pain to some degree. Sudden, severe
chest or abdominal pain following instrumentation or
surgery is very concerning for perforation. Patients on
immunosuppressive or anti-inflammatory agents may
have an impaired inflammatory response, and some
may have little or no pain and tenderness. Many
patients will seek medical attention with the onset or
worsening of the significant chest or abdominal pain,
but a subset of patients will present in a delayed
fashion (Aloysius et al., 2006).
Acute pain
Inflammation of the gastrointestinal tract, because of
perforation by a variety of etiologies, usually leads to
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some degree of neck pain (or dysphagia) or chest or
abdominal discomfort. The patient with a free
perforation often notes with precision the time of the
onset of the perforation. The patient may relate a
sudden worsening of pain, followed by complete
dissipation of the pain as perforation decompresses
the inflamed organ, but relief is usually temporary. As
the spilled gastrointestinal contents irritate the
mediastinum or visceral peritoneum, a more constant
pain will develop.
Acute symptoms associated with free perforation
depend upon the nature and location of the
gastrointestinal spillage (mediastinal, intraperitoneal,
retroperitoneal). Cervical esophageal perforation can
present with pharyngeal or neck pain associated with
odynophagia, dysphagia, tenderness, or induration.
Perforation of upper abdominal organs can irritate
the diaphragm, leading to pain radiating to the
shoulder. If perforation is confined to the
retroperitoneum or lesser sac (e.g., duodenal
perforation), the presentation may be more subtle.
Retroperitoneal perforations often lead to back pain
(Khalid et al., 2014).
Because the pH of gastric contents is 1 to 2 along the
gastric luminal surface, a sudden release of this acid
into the abdomen causes severe and sudden
peritoneal irritation and severe pain. The pH of the
stomach contents is often buffered by recent food
consumption. The leakage of small intestinal contents
into the peritoneal cavity may also cause severe pain,
and for this reason, any severe pain after, particularly
a laparoscopic procedure, should cause the surgeon to
suspectleakage (Isomoto et al., 2009).
Abdominal/pelvic mass
It is not uncommon for perforation to lead to an
abscess or phlegmon formation that can be
appreciated on examination as an abdominal mass or
with abdominal exploration. A pelvic abscess caused
by a perforation can sometimes be felt on digital
rectal examination. Diverticulitis is the most common
etiology leading to intra-abdominal abscess formation
(Brinster et al., 2004).
Fistula formation
A fistula is an abnormal communication between two
epithelialized surfaces. It can occur from bowel injury
during instrumentation or surgery, anastomotic leak,
or foreign body erosion. Fistulas are often related to
inflammatory bowel diseases such as Crohn’s disease.
Rarely, perforated colon carcinoma can fistulize to
adjacent structures or to the abdominal wall. The
initial gastrointestinal perforation is contained
between two loops of the bowel, and subsequent
inflammatory changes lead to abnormal
communication, which spontaneously decompresses
any fluid collection or abscess that has formed.
Patients who develop an external fistula will complain
of the sudden appearance of drainage from a
postoperative wound or from the abdominal wall or
perineum in case of spontaneous fistulas (Farrugia et
al., 2003).
Sepsis
Sepsis can be the initial presentation of perforation,
but its frequency is difficult to determine. The ability
of the peritoneal surfaces to wall off a perforation may
be impaired in patients with severe medical
comorbidities, particularly frail, elderly, and
immunosuppressed patients, resulting in free spillage
of gastrointestinal contents into the abdomen,
generalized abdominal infection, and sepsis (Moore
and Moore, 2013). Sepsis in itself can contribute to
the causation of perforation by reducing intestinal
wall perfusion (Merrell, 1995). These patients are very
ill-appearing, may or may not be febrile, and may be
hemodynamically unstable with altered mental status.
Anastomotic leak (e.g., colon surgery) can be
associated with increased fluid and blood transfusion
requirements(Behrman et al., 1998). Organ
dysfunction may be present, including acute
respiratory distress syndrome, acute kidney injury,
and disseminated intravascular coagulation. Timely
and adequate peritoneal source control is the most
important determinant in the management of
patients with acute peritonitis/abdominal sepsis. In
the Physiological Parameters for Prognosis in
Abdominal Sepsis (PIPAS) study, the overall in-
hospital mortality rate of 3137 patients was 8.9
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Int. J. Biosci. 2022
percent. Ten independent variables were associated
with mortality: malignancy, severe cardiovascular
disease, severe chronic kidney disease, respiratory
rate >22 breaths/minute, systolic blood pressure
<100 mmHg, unresponsiveness, room air oxygen
saturation level <90 percent, platelet count
<50,000/microL, and serum lactate level >4 mmol/L.
These variables were used to create the PIPAS
severity score. The overall mortality was 2.9 percent
for patients with scores of 0 to 1, 22.7percent for 2 to
3, 46.8 percent for 4 to 5, and 86.7 percent for 7 to 8
(Sartelli et al., 2019).
Physical examination of perforation
Physical exam should include vital signs; a thorough
examination of the neck, chest, and abdomen; and
rectal examination. In patients with gastrointestinal
perforation, vital signs may initially be normal or
reveal mild tachycardia or hypothermia. As the
inflammatory response progresses, fever and other
signs of sepsis may develop. Palpation of the neck and
chest should look for signs of subcutaneous gas and
auscultation and percussion of the chest for signs of
effusion. Mediastinal gas might be heard as a systolic
"crunch" (Hamman's sign) at the apex and left sternal
border with each heartbeat. Palpation reveals crepitus
in 30 percent of patients with thoracic esophageal
perforation and in 65 percent of patients with cervical
esophageal perforation (Sarr et al., 1982). Patients
with esophageal rupture caused by barotrauma can
have facial swelling. The abdominal examination can
be relatively normal initially or reveal only mild focal
tenderness, as in the case of contained or
retroperitoneal perforations. The abdomen may or
may not be distended. Distention is common in those
patients with perforation related to small bowel
obstruction. When free intraperitoneal perforation
has occurred, typical signs of focal or diffuse
peritonitis are present. The rectal examination may be
normal, as with contained upper abdominal
gastrointestinal perforation or reveal a palpable mass
in the cul-de-sac, representing a phlegmon or abscess.
There may also be rectal tenderness as well as
bogginess secondary to inflammation (Pieper-Bigelow
et al., 1990).
Laboratory studies of perforation
Laboratory studies are typically obtained in patients
who present with acute abdominal pain including
complete blood count (CBC), electrolytes, blood urea
nitrogen (BUN), creatinine, liver function tests,
lactate, amylase, and/or lipase. Serum amylase may
be elevated in patients with intestinal perforation due
to the absorption of amylase from the intestinal lumen
(Pieper-Bigelow et al., 1990). However, this finding is
nonspecific. Alterations in serum amylase can be due
to a variety of conditions, and many drugs affect
serum amylase values. C-reactive protein levels may
help to diagnose gastrointestinal leaks, particularly
after bariatric surgery or colorectal surgery.
It has also been useful for diagnosing perforation
associated with typhoid fever (Olubuyide et al., 1989).
Some inflammatory markers in drain fluid have also
been associated with anastomotic leak following
colorectal surgery. Although a diagnosis of the
gastrointestinal leak was made in the APPEAL study,
it was done in conjunction with imaging studies or
because of stool in the effluent (Komen et al., 2014).
Drain studies are generally unnecessary. In addition,
most surgeons do not routinely place drainage tubes
in the abdomen.
Non-surgical related constraints
Lack of water and sanitation, overcrowding
More diffuse access to water safety and sanitation is
fundamental for the control of typhoid fever, but the
related huge economic costs and long timelines will
not allow a short- to the middle-term solution.
Healthcare systems of poor resources countries,
especially when affected by internal or external
conflicts, may not afford the cost of these
socioeconomic improvements. Conversely, targeted
interventions on densely populated urban
communities like slums, where typhoid fever is a
serious problem, could be a possible way out. In the
meantime, fewer resources could be directed towards
rural areas with lower population density where
enteric fever is less common (Mweu and English,
2008; Breiman et al., 2012).
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Inadequacy of immunization programs
Almost all public health typhoid vaccination
programs in the groups of populations at greatest risk
have been performed in Asia, with the strongest
impact in endemic settings and in short- to medium-
term. The oral vaccine was found to be highly cost-
effective when targeting ages 1-14 years in high
burden/high-risk districts, as well as urban slums and
rural areas without improved water.
Remarkably, no vaccination experience has been
reported from sub-Saharan Africa, where emerging
threats, including multidrug resistance and increasing
urbanization, would warrant concentration on
immunization programs (Baker et al., 2016).
The recently proposed Typhoid Risk Factor (TRF)
index, which takes into account the drinking water
sources, toilet facility types, and population density,
seems a reliable tool to evaluate variations in the
disease burden, helping decision-makers to identify
high-risk areas and prioritize the right populations for
vaccination (Behrman, 2005).
Delay in surgical treatment
Timely surgical treatment can prevent the severe
peritoneal contamination observed in up to 70% of
patients, associated with a high mortality rate.
Moreover, early surgery might reduce the need for
extensive surgical procedures, with their contribution
to highmorbidity and mortality. From 30% to 100% of
perforated patients may wait a long period before
surgery, especially in rural areas and peripheral
facilities. Indeed the diagnosis can be challenging in
very young patients, in those who perforate while on
medical treatment or in the presence of a generalized
septic state, but if symptoms are evocative, diagnostic
confirmation by either abdominal x-ray or ultrasound
should not delay surgery. Similarly, adjustment of
electrolytes and fluid imbalance or anemia correction
should postpone surgery only for a short time as
prolonged resuscitation can adversely affect the
outcome (Hassan et al., 2010). Frequent causes of
surgical delay are protracted or late referral from
inadequate health facilities, difficult transport systems
(both ambulances and roads), difficulties sourcing
funds for treatment and diversion of patients to
alternative medical therapies before consulting the
hospital.
Surgical related constraints
Non-operative treatment has been proposed in the
past in moribund patients or for long-standing
perforations, but there is now uniform agreement that
the ultimate treatment for TIP should be a surgical
one, although the best surgical management remains
controversial. The type of surgical technique might
have limited influence on the outcome, which is likely
more related to the preoperative clinical conditions of
the patients, to the degree of abdominal
contamination and to the quality of pre- and post-
operative care (Mohil et al., 2008).
Scarcity of prospective studies and guidelines
Several surgical solutions have been proposed for the
treatment of TIP, with a consequent variability of
morbidity and mortality. Indeed, explicit surgical
guidelines, particularly aimed at resource-poor
countries, are lacking. Most reports are retrospective,
often including a small number of patients with
incomplete data and poor statistical analysis.
Surgical morbidity and mortality are often reported
without any risk adjustment based on the severity of
the disease, delay of treatment, etc. The few available
prospective studies highlight that patient’s conditions
have a more significant impact on patient’s outcome
than the type of surgical procedure (Tade et al., 2011).
Unavailable appropriate postoperative care
Postoperative care may be quite complex in these very
fragile patients, frequently presenting with a septic
state, coexistent diseases and an impaired
immunological status. Moreover, intensive care units
supplied for possible renal or respiratory failures,
with available appropriate antibiotics for
overwhelming infections and with accessible tools for
nutritional support, are found infrequently in
resource-poor countries, especially in peripheral or
rural settings (Ameh et al., 1999).
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Surgical technique
The type of the surgical procedure does not appear to
influence the mortality of TIP; conversely, sound
surgical judgment and experience are required to
select the appropriate surgery according to the
surgical findings and especially in advanced diseases
(Haider et al., 2002).
Primary repair is usually performed for single or
isolated perforations by single or two suture layers.
Segmental resection and anastomosis are preferred in
the presence of multiple adjacent perforations, while
wedge resection is reported infrequently. Simple
repair generally has a lower mortality rate than
resection, although the death rate remains high when
abdominal contamination is severe. The correlation
between a high number of perforations, perhaps due
to a highly virulent causative organism, and a poor
surgical outcome is questionable. Enterocutaneous
fistula is the most alarming complication, with a
mortality up to 67%, that is likely underestimated
because death can occur months after surgery
(Memon et al., 2012).
An ileostomy is usually reserved for patients with
severe disease, delayed presentation and very
contaminated abdomen, with a high risk of suture
leakage. Ileostomy has also been described as a
routine primary procedure, although it is associated
with a high morbidity rate and complications like
prolapse, stricture, retraction, parastomal hernia,
mainly when performed in patients with critical
conditions (Chaudhary et al., 2015). Moreover, loss of
intestinal fluids from ileostomy can be managed with
difficulty in an austere environment and shortage of
suitable ileostomy bags, with consequent skin damage
around ileostomies, not rarely inducing the patient to
a self-limitation of food intake.
Delayed primary closure of the abdominal wall has
been recommended for heavily contaminated wounds
for a long time, but to date, the optimal method of
closure in such situations remains controversial.
Vacuum-assisted closure appears promising but may
not be feasible in peripheral facilities. Scheduled re-
laparotomies, allowing early recognition of
complications and a more appropriate cleaning of the
abdominal cavity, have been performed with a
positive impact on survival. However, this policy has
the disadvantage of submitting the patients to
multiple surgical trauma and increasing the workload
of the operative theater (Pieper-Bigelow et al., 1990).
A laparoscopic approach to TIP has been occasionally
carried out with acceptable results (Sinha et al.,
2005). There is no evidence that laparoscopy is more
advantageous than open surgery, although it could be
considered as an advantageous diagnostic tool in
doubtful abdomens. A concern is a need for highly
technological equipment and appropriate
maintenance, often lacking in poor resources
countries.
Ileostomy care and complications
Ileostomy or colostomy creation may be required
temporarily or permanently for the management of a
variety of pathologic conditions, including congenital
anomalies, colon obstruction, inflammatory bowel
disease, intestinal trauma, or gastrointestinal
malignancy (Doughty, 2005). The anatomic location
and type of stoma construction have an impact on
management. Loop colostomies tend to be larger and
somewhat more difficult to manage than end
colostomies. The type and volume of output
(effluent), and therefore fluid loss, is determined by
the location of the stoma relative to the ileocecal valve.
Fluid loss is primarily a factor with end or loop
ileostomies. With proper stoma care and attention to
nutrition and fluid management, most ostomy
patients are able to have full, healthy, active social
and professional lives. In many cases, quality of life
can be improved, even in the context of a permanent
ostomy, with the treatment of the underlying disease
(Andrews and Ryan, 2015).
Patient education
The patient must adapt to new patterns of fecal
elimination and to their altered body and image of
themselves. Successful adaptation requires the
patient to master new skills and to deal effectively
with the many emotional issues associated with their
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altered anatomy and with altered continence.
Interventions that promote adaptation include
Preoperative stoma site selection by ostomy nurse
specialist (enterostomal therapy nurse, wound
ostomy continence nurse) or experienced surgeon.
Preoperative stoma site marking has been associated
with fewer ostomy-related complications (e.g.,
leakage, dermatitis), improved patients' ability to care
for the ostomy independently, and reduced health
care costs (Hendren et al., 2015). Position papers by
both the American Society of Colon and Rectal
Surgeons (ASCRS) and Wound Ostomy Continence
Nurse Society (WOCN) have been published to guide
proper stoma site markings (Salvadalena et al., 2015).
A strong focus on individualized patient education,
with a preoperative and postoperative component.
Supportive counseling for all patients preoperatively
and in-depth counseling for any patient who is having
trouble adapting (White, 2004).
Several studies have demonstrated that involvement
of an ostomy nurse specialist has a significant impact
on long-term positive outcomes and reduced
complication rates, as does involvement in ostomy
support groups such as the United Ostomy
Association of America (White, 2004).
Pouch system and routine ostomy care
Pouch systems
The main functions of ostomy pouches are to contain
the ostomy effluent, contain the odor, and protect the
peristomal skin. Many pouching systems are
available, as either one- or two-piece systems: One-
piece systems include a protective skin barrier with a
tape border fused to an odor-proof pouch. Two-piece
systems include a protective skin barrier with a tape
border and flange or adhesive landing zone to which
the patient attaches a separate odor-proof pouch.
One-piece systems offer simplicity, and many of these
systems provide flexibility, which is important for the
patient whose stoma is located in a deep crease. Two-
piece systems have the advantage that the pouch can be
replaced without having to remove the protective skin
barrier each time (Behrman et al., 1998).
Pouch placement
The patient should be taught strategies that can help
promote pouch adherence to the skin, minimize
leakage, and protect peristomal skin. These include:
Selecting a pouching system that conforms to the
abdominal contour at the stoma location. For
example, a flat pouch with a rigid flange requires a
relatively flat, at least 4 cm pouching surface that is
distant from scars, skin creases or folds, and bony
prominences (Suwanabol and Hardiman, 2018).
A stoma located in a concave abdominal plane may be
best managed with a convex pouching system, which
can increase protrusion of the stoma and improve
drainage of effluent into the pouch. Transverse loop
colostomies are typically large stomas in the upper
quadrants that are difficult to conceal, and prolapse is
more common. Cecostomies, now rarely performed,
are typically skin-level stomas located adjacent to the
groin crease, which compromises pouch adherence
sizing the opening of the protective skin barrier to
minimize the amount of exposed skin. Stomas often
change shape and size in the postoperative period.
After the stoma has assumed its final appearance
(usually several weeks after construction), a precut
protective skin barrier may be supplied, so the patient
or their caregivers do not need to cut out the barrier
ring each time a new appliance is placed. Using
adjunctive products to improve the fixation of the
pouch (adhesive agents, Skin Prep) and to prevent
irritation and injury to the peristomal skin (skin
barrier paste, skin barrier powder, skin barrier ring)
(Colwell, 2004). Loop ileostomies are typically more
difficult to manage than end ileostomies because the
stoma frequently empties close to the skin surface.
Because the small bowel effluent is rich in proteolytic
enzymes, the patient with an ileostomy must exercise
particular caution in managing the peristomal skin.
These patients should routinely use barrier wafers,
rings, and/or paste to assure that their skin is not
exposed to the drainage and must treat any minor
skin damage aggressively to prevent progression
(White, 2004).
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Pouch emptying and care
Odor and gas are common concerns for any
individual with an ostomy (Annells, 2006).
The patient should be assured that ostomy pouches
are odor-
proof, but when the pouch is emptied, the
odor is normal. Simple strategies can help reduce
odor. These include the following:
Emptying the pouch when it is approximately one-
third full will prevent disruption of the pouch seal
from excess weight.
Changing the pouch one to two times weekly, and as
needed, for any signs of leakage or for
itching/burning of the peristomal skin.
It was keeping the tail of the pouch clean so that it
does not become a source of the odor. This can be
accomplished by everting the tail of a pouch prior to
emptying it. For some pouches that have an
integrated closure mechanism, tail eversion is not
required.
Using a room spray or pouch deodorant to minimize
odor associated with emptying.
If the odor is a particular concern for the patient,
bismuth subgallate or chlorophyllin copper complex
effectively reduces stool odor when taken routinely.
Bismuth subgallate tends to thicken the stool, so it
may best be used for the patient with an ileostomy or
proximal colostomy.
Chlorophyllin may have a slight diarrheal effect and is
more appropriate for the patient with a
descending/sigmoid colostomy.
Diet and control of gas
Many patients assume that they will have to adhere to
a special diet because of their ostomy. Dietary
modifications are usually minimal, but specific foods
can influence the amount of the gas and the
consistency and odor of the effluent (Floruta, 2001).
Patients should be given a general list of gas-
producing foods. The carbohydrate raffinose is poorly
digested and leads to gas production by the action of
colonic bacteria. Common foods containing raffinose
include beans, cabbage, cauliflower, brussel sprouts,
broccoli, and asparagus. Starch and soluble fiber are
other forms of carbohydrates that can contribute to
gas formation. Potatoes, corn, noodles, and wheat
produce gas, while rice does not. Soluble fiber (found
in oat bran, peas and other legumes, beans, and most
fruit) also causes gas. Patients should also be given an
explanation that the usual "lag time" between
ingestion of a gas-producing food and actual
flatulence is between two to four hours for ileostomy
and six to eight hours for distal colostomy.
In addition to dietary modifications, ileostomy patients
should be taught to avoid drinking carbonated drinks,
drinking through straws, chewing gum, and smoking
since these measures tend to increasegas ingestion.
Strategies to control gas include measures to reduce
the volume of gas produced or to affect the "timing" of
flatulence, "muffling" measures and "venting"
strategies. Dietary modifications and over-the-
counter gas-reducing agents (e.g., Beano and Gas-X)
help reduce the volume of gas. "Muffling" measures
include layers of clothing and light pressure exerted
against the stoma with the hand or arm when
flatulence is anticipated.
For patients with large volumes of gas, there are
pouching systems with filters, which vent and
deodorize flatus; there are also "add-on" flatus filters
that can be used with any pouching system (Keenan
and Hadley, 1984).
Ileostomy patients
The type and volume of output (effluent), and
therefore fluid loss, is determined by the location of
the stoma relative to the ileocecal valve. Ileostomies,
cecostomies, and ascending colostomies typically
produce output (effluent) >500 mL per day that
contains digestive enzymes, which is irritating to the
mucosa and skin.
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Dehydration
Dehydration affects up to 30 percent of patients after
loop ileostomy creation and is the most common
cause for hospital readmission after ileostomy surgery
(Hayden et al., 2013).
How much fluid should an adult drink each day to
prevent dehydration? It is a simple question with no
easy answer, as studies have produced varying
recommendations. As examples:
The United States National Academies of Sciences,
Engineering, and Medicine (formerly the Institute of
Medicine) have recommended adequate intake (AI)
values for total water at levels to prevent
dehydration. The AI for men aged 19+ is 3.7 liters
each day, 3 liters (13 cups) of which should be
consumed as beverages. The AI for women aged 19+ is
2.7 liters, about 2.2 liters (9 cups) of which should be
consumed as beverages eachday.
The Dietitians of Canada have recommended 3 liters
(12 cups) for men 19 years old and over each day and
2.2 L (9 cups) for women 19 years old and over each
day.
The Eatwell guide of the British National Health
Service (NHS) has recommended drinking six to eight
cups or glasses of fluid a day.
Each cup or glass generally contains eight ounces of
fluid. Thus, eight cups of fluid would add up to 64
ounces or approximately 1.9 liters.
Regardless, patients with an ileostomy should be
instructed to increase their daily fluid intake beyond
the recommended AI for the general population by at
least 500 to 750 mL and to drink even more during
periods of high-volume output or heavy sweating.
Preferred fluids include water, broth, vegetable juices,
and some sports drinks, but patients should be
advised that certain sports drinks may not be
absorbed and may even exacerbate stoma output and
dehydration. The use of pediatric electrolyte solutions
(e.g., PediaLyte, Emergen-C) is preferable to the use
of sports drinks. Ileostomy patients and patients with
ascending colostomies should be taught the
importance of adequate daily fluid intake. The
average output for the ileostomy patient ranges from
500 to 1300 mL a day; during the early postoperative
period and episodes of gastroenteritis, daily output can
be 1800 mL or even higher (McCann, 2003 ). A loop
ileostomy performed in conjunction with a pelvic
pouch procedure is located more proximally in the
ileum and is associated with even more fluid and
enzymatic output. This daily fluid loss places the
ileostomy patient at greater risk for dehydration,
especially during episodes of increased output or
heavyperspiration.
Ileostomy effluent contains significant amounts of
sodium and potassium. Patients should also be taught
the signs and symptoms of fluid-electrolyte imbalance
and the importance of prompt treatment should these
symptoms occur. These include dry mouth, reduced
urine output, dark, concentrated urine, feelings of
dizziness upon standing, marked fatigue, and
abdominal cramping (Carmel and Goldberg, 2004).
Protocols and pathways have been proposed to
minimize dehydration and readmission in patients
with new ileostomies. Using combinations of
preoperative teaching, in-hospital engagement of the
nurses and Wound, Ostomy and Continence care
(WOCN) teams, in-hospital involvement and
encouragement of patients and families in stoma care,
postdischarge counseling, and tracking of intake and
output has effectively reduced hospital readmission
while maintaining an appropriate hospital length of
stay (Nagle et al., 2012).
High ostomy output
First-line management of patients with elevated
ileostomy output (defined as >1.5 L/day) should
include soluble fiber supplementation, also referred
to as bulk-forming laxatives, since they are primarily
used to treat constipation (e.g., Metamucil, psyllium,
Konsyl, FiberCon, Fiber Gummies). Patients may
slowly increase supplementation up to four times
daily and also at double doses. Medical management
of patients with inappropriately elevated ileostomy
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outputs is required in patients who do not respond to
fiber supplementation and includes antimotility
agents (e.g., loperamide [Imodium], diphenoxylate
and atropine [Lomotil], octreotide, cholestyramine,
and, rarely, tincture of opium). Rarely, patients with
difficult-to-control ileostomy output may need to be
maintained on intravenous hydration via a long-term
indwelling venous access cannula. Those with
persistent, recurrent, or difficult-to-manage
complications from loop ileostomy creation should be
considered for early reversal of the stoma and
restoration of intestinal continuity, when feasible.
Ileostomy patients with high output may need to
change to a protective skin barrier that is extended
wear and/or the addition of a skin barrier ring to
prevent washout of the skin barrier. Also, changing to
a high-output pouch would be beneficial for patient
management (Covarrubias et al., 2013).
Food blockage
Ileostomy patients should also be taught strategies to
prevent food blockage proximal to the ostomy site,
which can occur because theileal lumen is <1 inch (2.5
cm) in diameter. There is also the potential for
further narrowing at the point where the bowel passes
through the fascia/muscle layer. If the patient
consumes large amounts of insoluble fiber, the
undigested fiber may create an obstructing mass
(bezoar). Common "offenders" include popcorn,
coconut, mushrooms, black olives, stringy vegetables,
corn, nuts, celery, foods with skins, dried fruits, and
meats with casings. Food blockage is easily prevented
by instructing the patient to consume potential
offenders one at a time in small amounts, to chew
thoroughly, and to monitor their response (Carmel
and Goldberg, 2004).
Drug malabsorption
Because the small bowel is the most important site of
drug absorption, patients with an ileostomy are at
risk for suboptimal drug absorption. The patient with
an ileostomy must be taught to take medications in
dosage forms of quick dissolution, such as liquids,
gelatin capsules, and uncoated tablets, and avoid
time-released and enteric-coated medications as well
as very large tablets since these forms of medication,
are likely to be incompletely absorbed. Consult with a
pharmacist regarding medications that may not
dissolve or be absorbed appropriately. They must also
avoid laxatives due to the risk for acute dehydration
(Erwin-Toth and Doughty,1992).
Physical activity
A common concern for many patients is the impact of
the stoma on activities of daily living. The patient can
be reassured that most activities can be safely
resumed with minimal if any, modifications. As an
example, bathing and showering can be performed
with the pouch on or off, and clothing modifications
are generally not required. Most sports activities can
be resumed as well, with the exception of extreme
contact sports, which could potentially damage the
stoma. The addition of a belt or binder is helpful in
maintaining a pouch seal during vigorous activity and
with perspiration (Erwin-Toth and Doughty,1992).
Sex
Sexual activity is a particular concern for many
patients with an ostomy. Patient counseling should
address questions regarding sexual activity and
partner response (Manderson, 2005). The ostomy
does not affect organic sexual function. However, if
the ostomy was placed due to some form of pelvic
surgery or prior radiation treatment, it is possible that
the autonomic nerves controlling sexual function,
which are located adjacent tothe rectum and the pelvic
sidewall, may have been injured.
It is helpful for the patient to empty the pouch and
assure an intact pouch seal before engaging in sexual
activity. In addition, many patients and their partners
find it helpful to use lingerie or a cummerbund to
conceal and secure the pouch. Commercial pouch
covers, lingerie, and undergarments specifically
designed for ostomates are available (White, 2004).
Travel
Patients who are traveling should be advised to:
Take extra ostomy supplies, and if flying, place them
in carry-on luggage.
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Some airports offer private pre-screenings upon
request.
Avoid exposing ostomy pouches and adhesive
adjuncts to extreme temperatures, which may alter
the adhesive quality.
Drink only bottled water if local tap water is not known
to be safe.
Ostomy complications
The incidence of stomal complications ranges from 14
to 79 percent (Persson et al., 2010), nearly half of all
stomas eventually become "problematic" due to
pouching and peristomal skin issues (Caricato et al.,
2007). Complications vary with the type of ostomy,
with lower complication rates for those with end
colostomy and end ileostomy (Güenaga et al., 2007).
Loop ileostomies have the highest complication rates.
The most common problems of end and loop
ileostomies are dehydration and skin irritation
(related to the high-output, high alkaline enzymatic
effluent), and small bowel obstruction.
Although prolapse can occur in all types of stomas, it is
more prevalent in loop colostomies, particularly those
constructed using the transverse colon. Parastomal
hernia and retraction are the most common
complications for end and loop ileostomies and
colostomies (Güenaga et al., 2007). Stomal and
peristomal complications can occur in the early
postoperative period or many years following stomal
construction (Nastro et al., 2010). Although profiles
of early and late ostomy complications do overlap
(e.g., stomas can retract early or late), they are often
quite different:
Very early complications (days)
Complications that occur very early in the
postoperative course (days) are often related to
technical issues (Cottam et al., 2007) and often
require a return to the operating room. Examples
include large bowel obstruction due to a twist in the
bowel leading to the stoma.
Early complications (<3 months)
Early complications, defined as those occurring
within three months of stoma construction, are often
related to suboptimal stoma site selection but are
heavily influenced by patient factors (e.g., old age, poor
nutritional status, higher American Society of
Anesthesiologists [ASA] class, comorbidities, obesity,
tobacco use, and underlying malignancy) (Cottam et
al., 2007). Early complications include stomal
ischemia/necrosis, stomal bleeding, stomal
retraction, and mucocutaneous separation.
Stomal necrosis
The incidence of stomal necrosis in the immediate
postoperative period is as high as 14 percent.
Adequate mobilization of the bowel, preservation of
the blood supply to the stoma, and an adequate
trephine size are important factors for avoiding this
complication. Independent risk factors for stomal
necrosis include emergency surgery, obesity, and
inflammatory bowel disease, in particular Crohn
disease (Leenen and Kuypers, 1989).
Stomal necrosis most commonly occurs in the early
postoperative period as a result of venous congestion
or arterial insufficiency (e.g., tight fascial opening,
excessive mesenteric stripping). The most critical
assessment is to determine the extent of necrosis,
which can be performed by inserting a lubricated
test tube into the stoma and using a flashlight to
visualize the proximal mucosa. An alternative is to
use a flexible sigmoidoscope or a lighted anoscope.
Management is based upon the clinical scenario:
If the necrosis extends to the proximal bowel below
the anterior fascia, immediate revision is required.
If the proximal bowel is viable and the necrosis is
limited to the stoma (superficial to the anterior
fascia), observation may be appropriate.
If necrosis progresses, a revision is required.
If sloughing occurs, only gentle debridement may be
necessary. Sloughing of the stoma can result in stomal
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Int. J. Biosci. 2022
retraction and pouching challenges but may not
require surgical intervention.
In acute settings, stoma ischemia is more often
limited to the mucosa above the fascia and thus can
be observed, albeit with a possible resultant stricture
in the future (Paquette, 2018).
Stomal bleeding
Major bleeding from the stoma (as opposed to a
gastrointestinal bleed) is uncommon and usually
indicates either a stomal laceration from a poorly
fitting appliance or the presence of peristomal varices
in the patient with portal hypertension. Minor
bleeding from the stoma can also occur early in the
postoperative period related to the creation of the
stoma or later with overly vigorous stomal cleansing.
Initial management of stomal bleeding involves direct
pressure and local cauterization (handheld cautery,
silver nitrate) or suturing of the bleeding vessel is
easily identified. Peristomal varices are most
frequently seen in patients who underwent a
colectomy for ulcerative colitis in the setting of
primary sclerosing cholangitis. Peristomal varices can
also develop in patients with other causes of portal
hypertension. Initial management consists of direct
pressure followed by injection sclerotherapy or direct
suture. However, recurrence is frequent, and medical
therapy or intervention (e.g., transjugular
intrahepatic portosystemic shunting) may be needed
to reduce portal pressures (Harris et al ., 2005).
Stomal retraction
Stomal retraction is defined as a stoma that is 0.5 cm
or more below the skin surface within six weeks of
construction, typically as a result of tension on the
stoma. Stomal retraction leads to leakage and
difficulties with pouch adherence, resulting in
peristomal skin irritation. The incidence of stomal
retraction ranges between 1 and 40 percent. The most
common risk factors are obesity due to the thickness
of the abdominal wall and foreshortened mesentery
and initial stoma height <10 mm (Cottam et al.,
2007). Proper stoma height and minimizing tension
are important factors for preventing this
complication. Management also depends upon the
clinical scenario:
If the stoma retracts below the fascia, immediate
operative revision is required to prevent intra-
abdominal contamination from the stoma output.
A stoma that has retracted but stays above the fascia
can be managed with local wound care, a convex
pouching system, and the use of a belt or binder. If
these measures fail to provide a secure pouch seal,
surgical revision may be needed. However, revision is
appropriate only when an improved outcome can be
expected and is not appropriate when the cause of the
problem has not been addressed. Approximately 1
percent of patients experience stomal retraction as a
result of postoperative weight gain. Overweight
patients should be encouraged and assisted to lose
weight prior to surgical revision.
If nonoperative management of a retracted stoma
fails, operative revision or re-siting of the stoma is
necessary. Re-siting the stoma to the upper abdominal
wall, which is usually thinner, may be helpful.
Mucocutaneous separation
Mucocutaneous separation refers to the separation of
the ostomy from the peristomal skin. Mucocutaneous
separation results in leakage and skin irritation. It
occurs in 12 to 24 percent of patients early in the
postoperative period (Cottam et al., 2007).
The best approach to preventing this complication is
the meticulous technique when approximating the
bowel to the skin. Mucocutaneous separation can be
partial or circumferential; if circumferential, stomal
stenosis can occur as the tissues heal by secondary
intention. Circumferential separation of the suture
line with retraction of the stoma should be revised
immediately. For less severe separations, the defect
can be filled with absorptive material, such as calcium
alginate, skin barrier powder, paste, or hydrofiber.
Covering the area with the protective skin barrier
with a barrier ring will help protect the wound from
effluent and facilitate healing.
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Late complications (>3 months)
Late stomal complications are generally described as
permanent ostomies since many temporary stomas
are reversed within three months. Risk factors for late
complications include duration of stoma, increases in
intra-abdominal pressure (obesity, chronic
obstructive pulmonary disease), emergency surgery
(Harris et al., 2005). Inadequate mobilization of the
bowel with the resultant height of stoma <10 mm, and
inappropriately sized aperture.
The most common late complications include
parastomal hernia, stomal prolapse, and stoma
stenosis. A closed stoma site following ostomy
reversal can also be associated with complications
such as wound infection, delayed healing, and hernia
formation.
Parastomal hernia
Parastomal hernia formation is a common
complication, especially among colostomy patients.
Risk factors include obesity and poor abdominal
muscle tone, conditions producing a chronic cough,
placement of the stoma outside of the rectus muscle,
and a large fascial opening. Most parastomal hernias
are asymptomatic and do not progress to
complications (e.g., incarceration, strangulation,
bowel obstruction) (Colwell, 2005).
Stomal prolapse
Prolapse is the telescoping of the intestine out from
the stoma and can occur with any type of stoma.
Prolapse can make appliance placement and
adherence difficult, and prolonged prolapse causes
intestinal edema and, if significant, can lead to
intestinal incarceration or strangulation. The
incidence ranges from 7 to 26 percent, with the
highest rates associated with a loop transverse
colostomy and end descending colostomies (Cheung,
1995). Risk factors for prolapse may include a large
abdominal trephine, increased intra-abdominal
pressure, and a redundant loop of bowel proximal to
the stoma. Alternative fixation techniques during
ostomy construction have been proposed to prevent
prolapse (Maeda et al., 2003). However, there are no
data to support these approaches.
Uncomplicated prolapse can be managed
conservatively with cool compresses and/or
application of an osmotic agent (e.g., table sugar or
honey) to reduce edema, followed by manual
reduction of the prolapse and application of a binder
with a prolapse over-belt to keep the bowel recued
into the abdomen, or by pouching modifications to
accommodate the prolapsed bowel when reduction
cannot be established or maintained (Shapiro et al .,
2010). The manual reduction should be initiated at the
very tip of the prolapse (beehive) or lumen, and then
gentle, slow invagination should proceed. In this way,
the prolapsed bowel will intussuscept back into the
abdomen. Complicated prolapse or prolapse
producing ischemic changes or severe mucosal
irritation and bleeding usually requires surgical
intervention. Local revision of the prolapse is
accomplished by performing a full-thickness resection
of the prolapsed intestinal segment with the
construction of the stoma at the original site. In the
event of a further recurrence, additional bowel
resection and relocation of the stoma may be
necessary (Paquette, 2018).
Stomal stenosis
Stomal stenosis refers to a narrowing of the stoma
sufficient to interfere with normal function. The
incidence ranges from 2 to 15 percent and is more
common with an end colostomy (Beraldo et al.,
2006). Stomal stenosis can occur in the early
postoperative period but is more likely to develop
months later. Early stenosis of ileostomy, due to
edema at the fascial and more superficial levels
(assuming appropriate skin opening), can be
conservatively managed with gentle insertion of a large
36 French soft-tipped Foley bladder catheter just
proximal to the fascial level. The balloon should not be
inflated. If there is significant resistance upon
intubation of the stoma, the procedure should be
abandoned. Care must be taken to avoid perforation.
Stenosis can occur later at the skin or the fascia level,
or stoma outlet secondary due to scarring or tightness
of the mucocutaneous junction. Stenosis may be
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Int. J. Biosci. 2022
attributable to peristomal sepsis, retraction, an ill-
fitting pouching system, or suboptimal surgical
technique. The patient should be evaluated for other
processes that could contribute (e.g., Crohn's disease,
primary or recurrent malignancy).
Mild stenosis may be identified only by digital
examination of the stoma, with few symptoms, and
can usually be managed by dietary modifications (e.g.,
avoidance of insoluble fiber); gentle routine dilatation
of the stoma may also be helpful but is not evidence-
based (Harris et al., 2005).
Clinically significant stenosis usually causes cramping
pain followed by explosive output and usually
requires surgical correction. For these, local revision
may be preferred over dilation, which can be
complicated by peristomal bleeding, tissue injury,
fibrosis, and further stenosis. Local repair involves the
excision of scar tissue with adequate mobilization and
creation of a new tension-free stoma at a new or
relocated site. Enlargement of the skin opening via a
double Z-plasty technique may be useful in some
situations (e.g., limited number of sites for ostomy
relocation, limited scarring) (Lyons and Simon, 1960
).
Peristomal skin problems (any time)
The most common ostomy complication is peristomal
skin breakdown, with varying severities from minor
skin trauma to dermatitis, to ulceration, to pyoderma
gangrenosum (in Crohn patients). Peristomal skin
breakdown can occur early or late and is more
prevalent with ileostomies than colostomies (Shapiro
et al., 2010).
Mechanical trauma
Mechanical trauma typically presents as patchy areas
of irritated, denuded skin that result from repeated
removal of adhesive products or overly aggressive
cleansing techniques. Patients with peristomal hair
should be taught to clip the hair to prevent
mechanical trauma to the hair follicles. Patients
should be taught to use plasticizing skin sealants to
help prevent skin damage (skin sealants are optional
and specific to the manufacturer) with pouch removal
and should be cautioned to use a gentle technique
when cleaning the peristomal skin.
Treatment involves the elimination of the causative
factors and application of skin barrier powder to the
involved areas, followed by blotting with a skin
sealant or moistened finger to provide a nonpowdery
pouching surface (Colwell, 2004).
Dermatitis
Peristomal skin irritation is more common for
patients with an ileostomy due to the nature of the
effluent. It is characterized by severely denuded skin
along the inferior aspect of the stoma. Creating a
protuberant spout for the ileostomy approximately 2
to 3 cm high to optimize pouch fit is the best method
to minimize contact of effluent with the skin (Colwell,
2004). Peristomal skin irritation can also result from
mechanical trauma, an allergic reaction to a pouching
product, or peristomal fungal infection, which is more
common in warm and humid climates or related to
antibiotic therapy (Shabbir and Britton, 2010).Fungal
infections present as a maculopapular rash with
distinct satellite lesions. Allergic reactions can occur
with any of the products used to protect the
peristomal skin or to assure adhesion of the pouching
system; allergic reactions are characterized by
pruritus, erythema, and blistering in the area
corresponding to and demarcated by contact with the
offending agent (Nastro et al., 2010).
Treatment involves identification and correction of
the causative factors, elimination of any allergens, and
treatment of the denuded areas with skin barrier
powder or an antifungal powder (e.g., nystatin or
miconazole). If necessary, the powder can be lightly
blotted with a moist finger or skin sealant to assure a
pouchable surface (Erwin-Toth, 2000). Topical
steroids may sometimes be required for a severe
reaction. Whenever possible, the patient with
peristomal skin problems should be seen by an
ostomy nurse specialist. Refractory peristomal skin
breakdown should prompt a referral to a surgeon with
experience and expertise in stoma management.
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Parastomal ulceration
Parastomal ulceration, defined as discontinuity of
peristomal skin with adjacent inflammation, is
usually the result of an infected postoperative
hematoma or intestinal fistula (Akinwale et al., 2016).
Granulomas
Granulomas are red, moist, elevated lesions at the
mucocutaneous border. Often they are a result of
retained suture or other extraneous material.
Granulomas bleed easily and may be tender. They
may become infected. Maintaining barrier seals can be
a problem. Treatment consists of examining and
removing any extraneous material and eliminating
the lesion. Silver nitrate should be applied to remove
the elevated tissue. Several treatments may be
necessary. After treatment and until healed, the area
should be crusted with barrier powder and a skin
sealant. If extensive, the pouching system may need to
be adjusted until the area heals. Failure of lesions to
heal or frequent reoccurrence should be evaluated for
other pathology (Carmel et al., 2016).
Peristomal pyoderma gangrenosum
Pyoderma gangrenosum (PG) is a neutrophilic
dermatosis with unclear etiology. Peristomal
pyoderma gangrenosum (PPG) is a subtype of PG that
occurs at the stoma site, typically in patients with
inflammatory bowel disease (IBD). PPG occurs in 0.5
to 1.5 per million people annually, which accounts for
15 percent of PG cases (Afif et al., 2018). According to
a 2019 systematic review (79 studies; 335 cases), most
PPG patients are female (67 percent), with a mean
age of 48 years and a diagnosis of IBD (81 percent;
Crohn's disease 50 percent, ulcerative colitis 31
percent). PPG has also been identified in patients with
intra- abdominal malignancies (Hughes et al., 2000).
Ileostomies, colostomies, and other stomas
(urostomies) are involved in 78, 16, and 6 percent of
patients.
PPG can develop within weeks to years after stoma
construction, with an incidence of <1 percent of
stomas (2 to 4 percent in those with IBD) (Walling
and Sweet,1987; Lyon et al., 2000; Callen 1998).
Sixty-nine percent of patients reported an IBD flare
with the onset of PPG.The lesions typically present as
full-thickness ulcers, and pain and pathergy are
dominant characteristics. The diagnosis of PPG is
clinical and usually one of exclusion since there is no
definitive diagnostic test. The lesion is frequently
misdiagnosed as a stitch abscess, contact dermatitis,
urinary or fecal fistula, an extension of Crohn's
disease, or a wound infection. Patients with suspected
PPG should be referred to a dermatologist for
possible biopsy (Güenaga et al., 2007).
Biopsy of the skin lesion is nondiagnostic but does
help to exclude certain pathologies (e.g., cancer,
Crohn's disease) (Hughes et al., 2000). If a skin
biopsy is performed to rule out other pathology, acute
and chronic inflammation is the typical finding. The
biopsy should be performed with caution as this may
increase the size of the wound. Granulomas may be
noted on microscopic examination. Biopsies should
be performed at the leading edge of the ulceration
with 4 to 6 mm punch biopsies. Similarly, cultures
should also be obtained to evaluate for any infectious
etiologies; PPG ulcers are sterile or grow commensal
skin or gut flora. Selecting an unaffected segment of
the bowel for the stoma is the best way to prevent this
complication. However, once occurring, these lesions
are managed by systemic, intralesional, and/or
topical anti-inflammatory agents, depending on
severity (Afif et al., 2018).
Mild cases of PPG without the active systemic disease
can be managed with topical agents. Topical therapies
for PPG include corticosteroids and calcineurin
inhibitors (e.g., tacrolimus) with similar clinical
efficacies (62 versus 56 percent). Intralesional
injection of corticosteroids is less effective and, in
some cases, worsened PPG.
More severe or rapidly evolving cases of PPG require
systemic medication or even surgical intervention.
Corticosteroids are the most commonly used systemic
treatment, with a complete response rate of 52
percent in 146 patients. Other systemic options with a
similar (50 percent) response rate include
19. 109 Urooj et al.
Int. J. Biosci. 2022
cyclosporine and dapsone. Systemic metronidazole,
azathioprine, sulfasalazine, and tacrolimus are less
commonly used. Tumor necrosis factor alpha
inhibitors such as infliximab and adalimumab are
favorable therapeutic options for PPG concomitant
with active IBD and can be used for refractory PPG
regardless of whether IBD is present.
Wound care is critical for PPG management. The
overall goals are to provide a clean wound
environment, absorb exudate, maintain moisture, and
prevent further skin damage (Stamm et al., 1995)
Care must be taken to minimize trauma since
pathergy is a prominent feature of these lesions.
Dressings should be nonadherent, and stoma
management should be modified to minimize trauma
to the affected area (Kiran et al., 2005).
Surgical management may be required for
intractability (most common), severe colitis, or
complications (e.g., perforation, stenosis, obstruction,
herniation). The success rate depends on surgical
technique (Afif et al., 2018).
Stoma closure or resection of bowel with active IBD
completely healed PPG with few recurrences in small
case series.
Stoma relocation resolved PPG in almost all patients,
but 67 percent recurred at the new stoma location.
Wound debridement was less effective, associated
with only26 percent complete response.
Continent ileostomy complications
Patients with a Kock pouch or Barnett Continent
Ileostomy Reservoir can develop nipple valve slippage,
which presents as obstruction or inability to
appropriately intubate and evacuate intestinal
contents. Surgical management is indicated.
Revision may be possible; however, some situations
require resection and reconstruction of a new
continent-type ileostomy or end-ileostomy (Beraldo
et al., 2006).
Conclusion
Most gastroduodenal perforations are spontaneous
from peptic ulcer disease. The management is not
standardized as it essentially depends on the clinical
scenario and the surgeon's experience. A perforated
peptic ulcer is an indication for operation in nearly all
cases except when a patient is unfit for surgery.
Surgical techniques are varied, but laparotomy and
omental patch repair remain the gold standard, while
laparoscopic surgery should only be considered when
expertise is available. This must be followed by H.
pylori eradication therapy to prevent a recurrence.
Gastrectomy is recommended in patients with large
or malignant ulcers to enhance outcomes. Primary
closure is achievable in traumatic perforation, but
with the exsanguinating critically ill patient in severe
major trauma, damage limitation surgery to correct
physiology prior to a later anatomical reconstruction
is the principle of management.
Acknowledgement
This study pays special thanks to the Director China
Study Center University of Balochistan for his
support, advice, and guidance.
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