A Rare Case of Recurrent Generalized Peritonitis Caused by Spontaneous Urinary Bladder Rupture after Radiotherapy: A Case Report and Literature Review

Since generalized peritonitis is a fatal disease, accurate diagnosis and treatment are important. In this paper, we report a case of recurrent generalized peritonitis associated with spontaneous urinary bladder rupture (SBR). A 65 year old woman, who underwent radiotherapy 21 years prior, was diagnosed with generalized peritonitis. Although the cause of the generalized peritonitis could not be identified, the patient recovered with conservative treatment in short period. However, recurrent episodes of generalized peritonitis occurred four times. We diagnosed the patient with urinary ascites due to SBR, based on a history of radiotherapy and dysuria. No recurrence of generalized peritonitis had occurred after accurate diagnosis and treatment with long-term bladder catheter placement. Since SBR often occurs as a late complication after radiotherapy, it is difficult to diagnose SBR, which leads to delayed treatment. This case and literature review of similar cases suggest that the information of the following might be helpful in the diagnosis of SBR: (i) history of recurrent generalized peritonitis, (ii) pseudo-renal failure, (iii) history of radiotherapy, (iv) dysuria, and (v) increase or decrease of ascites in a short period. It is important to list SBR in the differential diagnosis by knowing the disease and understanding its clinical features. This case and literature review will serve as a reference for future practices.

CURRENT GUIDELINES ON EVIDENCED-BASED DIAGNOSIS AND MANAGEMENT OF ACUTE APPENDICITIS

Introduction: Appendicitis is the inflammation of the vermiform appendix. Appendicitis can be considered the most commonly interpretive cause of acute and severe abdominal pain. Acute Appendicitis (AA) is mainly caused by luminal obstruction obstructed by numerous etiologies. This causes an increase in the rate of bacterial overgrowth and mucus production thereby causing necrosis, wall tension and potential perforation. Materials and Methods: The study is a Retrospective cohort and was conducted during the periods of 11 months. The study included 97 patients with appendicitis and divided them based on the protocol by which they receive diagnosis and management. Out of 97 patients, 49 patients were assigned to group 1 and the other 48 patients were assigned to group 2. Group 1 includes those patients who were treated symptomatically and diagnosis and management were given to them according to the wish of the consulting physician. For the determination of outcomes of treatments given to Group 1 and Group 2 patients, the study considered complications found in the patients. These complications are recorded for each of the groups. Also, the study recorded the complication in each of the treatment methods of Group 1 patients. This allowed the authors of this study to find out how outcomes vary when treatment is given differently from that of Alvarado Scoring criteria. Results: The complications that were found in the study participants are fever, generalized peritonitis, perforation, abscess, a mild respiratory infection. The study found that the complications among the patients in Group 1 and Group 2 separately. In Group 1, 8 patients had a fever, while 3 patients had a fever in Group 2. Group 1 patients had all the listed complications including perforation (n=7), abscess (n=4), mild respiratory infection (n=3) and peritonitis (n=2). In Group 2, only 4 patients showed complications including fever in 3 patients and perforation in 1 patient. Conclusion: The study has concluded that following Alvarado criteria in diagnosis and management of acute appendicitis results in the least possible complications. The study suggests the clinicians follow Alvarado criteria for proper management of acute appendicitis. Keywords: Acute appendicitis, Alvarado criteria, appenditis complications, appendicitis diagnosis, appendicitis treatment

Factors of unfavorable outcome of generalized peritonitis

Aim. To analyze clinical and bacteriologic factors associated with the occurrence of septic shock and mortality in patients with secondarily generalized peritonitis.Materials and methods. The analysis of the results of the examination and treatment of 180 patients with generalized peritonitis was carried out. Patients were divided into two groups: the first group of 74 patients (41.1%) who had septic shock and the second group of 106 patients (58.9%) without a record of septic shock. Further, subgroups of patients with community-acquired and postoperative generalized peritonitis were identified in a ratio of 112/68.Results and discussion. Mortality among patients with community-acquired peritonitis was 21% and among patients with postoperative peritonitis - 16%. 42 (37%) patients with community-acquired peritonitis developed septic shock compared with 32 (47%) cases of shock among patients with postoperative peritonitis. Patients who developed septic shock were significantly older than patients without septic shock in both subgroups. In both types of generalized peritonitis, anaerobes are significantly associated with septic shock.Conclusions. It was revealed that age over 65 years, two or more microorganisms of the peritoneal fluid, or anaerobes were independent risk factors for the development of septic shock. Peritoneal exudate yeast and enterococci were associated with septic shock in a subgroup of patients with community-acquired peritonitis. Yeast was associated with high mortality in postoperative peritonitis.

Management of Complicated Appendicitis in Al-Thawra Modern General Hospital Sana'a -Yemen from November 2019 to November 2020: علاج التهاب الزائدة الدودية المعقد

Background: Complicated appendicitis causes morbidity and mortality more than simple appendicitis. Complicated appendicitis includes appendicular mass, appendicular abscess, perforated appendicitis. Objective: To study presentation of complicated appendicitis regarding to age, sex and complain duration, also to study management of complicated appendicitis and his response to conservative management. Methods: A prospective, observational study was conducted in the department of general surgery at AL-Thawra hospital during the period from Nov 2019 to Nov2020. The data was collected using clinical examination and follow up, and was analyzed using SPSS 24. Results: A total of 57 patients diagnosed as complicated appendicitis, aged from 6 to 60 years were admitted, mean age was 28 years. Male to female ratio was 1.6:1. The complaint duration was more than 3 days in 34 cases (59%), total leucocytes count was >18 × 103 in 28 cases (49.1%). Twenty patients (35.1%) diagnosed as generalized peritonitis, 18 cases (31.6%) diagnosed as localized peritonitis, 14 patients (24.6%) diagnosed as appendicular mass, and 5 cases (8.8%) diagnosed as appendicular abscess. Forty cases (70.2%) underwent surgical intervention, whereas 17 cases (29.8%) improved with conservative management. Fifteen cases (37.5%) of operated patients underwent simple appendectomy and 13 cases (32.5%) underwent appendectomy with drain, and 12 cases (30%) underwent midline laparotomy. Most appendicular mass cases 12 (85.7%) were managed conservatively and 2 cases (14.3%) were operated. Three cases (60%) of appendicular abscess were aspirated, 2 cases (40%) were drained. Surgical site infection was 27.5% of operated cases. Conclusions: Complicated appendicitis can be suspected through clinical presentation, duration of complains and inflammatory response. Management of complicated appendicitis varies accordingly from conservative conventional to midline laparotomy.

Unusual complications of a common disease in COVID times: a case series

Acute appendicitis is the most common abdominal surgical emergency worldwide. 20-30% of cases of appendicitis can complicate which is defined as perforation, purulent peritoneal collection, abscess formation and generalized peritonitis. The risk of perforated appendicitis increases when appropriate treatment for acute appendicitis is delayed. There has been an avoidance of both urgent or emergency and routine medical care because of Coronavirus disease 2019 (COVID-19) concerns all over the world. In our study, the delayed presentation of the patients with acute appendicitis to the hospital prevented appropriate management leading to a much more morbid disease course. Increasing accessibility of medical and telehealth services might help prevent delay of needed care. Even during the COVID-19 pandemic, persons experiencing a medical emergency should seek and be provided care without delay.

RESULTS OF THE IMPACT OF ANTIPROTEINASE HEMOSORBENT ON THE DYNAMICS OF CLINICAL AND LABORATORY INDICATORS IN CHILDREN WITH GENERALIZED PERITONITIS

Background. Despite the undoubted success of modern medicine, peritonitis in children remains not only a surgical, but also a general pathological problem, the relevance of which is not decreasing. The use of efferent therapy methods, in particular hemosorption, imitating the natural mechanisms of detoxification of the body, are promising in the complex therapy of children with peritonitis. The aim of the study was to establish the effectiveness of the antiproteinase hemosorbent "Hemo-proteazsorb" in the complex intensive care of children with generalized peritonitis. Material and methods. A prospective randomized study of 60 children with generalized peritonitis was conducted. In the main group, there were 30 patients who underwent hemosorption in complex intensive therapy. The comparison group also included 30 patients who underwent traditional treatment. The examined groups were comparable in terms of the nature of the pathology and the severity of the condition. Results. During hemoperfusion, a significant increase in blood saturation was established – from 95.1 (93.2; 97.1)% to 97.3 (95.5; 98.7)%, with an improvement in oxygen transport (ctO2, mmol/l) from 6.9 (6.4; 7.9) to 8.8 (1.5; 9.7) and a decrease in lactate level (mmol/l) from 1.7 (1.5;2.1) to 1.1 (0.9;1.3), which indicated normalization of blood oxygenation and improvement of microcirculation. After 24 hours, there was a significant decrease in the sum of points on the pSOFA scale, from 4.5 (3.0; 6.0) to 0.5 (0; 2.0), p<0.001. Normalization of body temperature and restoration of intestinal function in 15 (50.0% СI 32.1-67.9) children were also noted, which indicated a decrease in multiple organ dysfunction and improvement of the condition. In the comparison group, the studied indicators changed much more slowly. Conclusions. The data on the positive dynamics of clinical and laboratory parameters, obtained as a result of the study, prove the high effectiveness of the Belarusian hemosorbent "Hemo-proteazsorb" in the complex intensive care for generalized peritonitis.

896 Can We Count on Serum Hyperbilirubinemia to Predict Acute Complicated Appendicitis?

Aim Acute appendicitis (AA) is usually a clinical diagnosis and surgical intervention is typically a preferred choice to avoid potentially lethal complications like perforation and purulent peritonitis. Intra-abdominal inflammation can lead to hepatic cholestasis due to cytokine release, which can reflect as rise in bilirubin alone or in combination with other liver enzymes. The aim of this study was to evaluate hyperbilirubinemia as a predictor of complicated acute appendicitis (CA). Method A retrospective analysis of all the patients who underwent surgery for AA in a district general hospital in the UK from Jan 2018 to April 2019. All the patients underwent admission blood tests including White cell count (WCC), C- reactive proteins (CRP), and liver function tests (LFTs). For data collection hospital medical record was used. Complicated appendicitis (CA) was defined as Gangrenous, or perforated appendix wall, abscess formation, or generalized peritonitis. Results In total 236 patients underwent appendectomy. On histology 25 patients (10.6%) had normal appendix (NA). Furthermore, 161 patients (68.2%) had uncomplicated appendicitis (UA) and 50 patients (21.2%) had complicated appendicitis (CA). Serum Bilirubin (SB) was found to be statistically significantly raised in patients with CA (p value=0.0001) when compared with NA group. Overall sensitivity of SB, CRP and WCC for AA was(15.17%, 79.90%, and 57.82% respectively) and specificity was(100%, 36.36% and 68% respectively). Conclusions SB had low sensitivity and high specificity as compared to CRP and WCC for AA. Raised serum bilirubin levels can be considered as one of the supportive markers of complicated appendicitis.

Emergency Treatment of Transverse Colon Cancer

This chapter deals with the emergency treatment of transverse colon cancer. The main complications that classify transverse colon cancer in an emergency setting are obstruction, perforation accompanied by localized or generalized peritonitis, and hemorrhage which may be occult or cataclysmic with hemorrhagic shock. We present the technical principles of radical surgical resection using embryological, anatomical, and oncological concepts. In this chapter we also discuss the principles of lymphadenectomy associated with complete excision of the mesocolon with high vascular ligation, in particular with T3 or T4 cancers requiring D2/D3 lymphadenectomy. The use of infrapyloric, gastro-epiploic, and prepancreatic lymphadenectomy is recommended due to the frequent metastases in these regional lymph nodes.