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A CLINICAL STUDY TO ANALYSE THE SPECTRUM OF PERITONITIS DUE TO HOLLOW VISCUS PERFORATION
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To determine the role of enteric fever in ileal perforations.
A prospective cohort of 47 patients of ileal perforation was subjected to clinical examination and investigations for APACHE II scoring. Blood, ulcer edge biopsy, mesenteric lymph node and peritoneal aspirate were subjected to culture to determine the predominant aerobic bacterial isolate and its antibiogram.
Seven patients (14.9%) required intensive care and seven (14.9%) developed septicaemia. Mortality was 17%. Highest isolation rate was seen in ulcer edge (70.2%) followed by lymph node (66%) culture. The bacterial spectrum was Escherichia coli (23.4%), Enterococcus faecalis (21.3%), Salmonella enterica serovar Typhi (6.3%), Salmonella enterica serovar Paratyphi A (4.2%), etc.
Enteric fever organisms are not the predominant causative agents of ileal perforations. Culture of ulcer edge biopsy, lymph node is crucial for aetiological diagnosis. The use of APACHE II triaging and prescription of antimicrobials based on the local pattern of susceptibility profile of the aetiological agent is recommended.
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ALTHOUGH several features of peptic ulcer disease have been elucidated over the past few years, new questions have replaced those that have been answered. Some of the factors that may predispose people to the development of peptic ulcers have been identified, but how they produce their effects and how they can be combated therapeutically remain unclear. This seminar briefly reviews current knowledge about the pathogenesis of peptic ulcers and discusses strategies for treatment. Defense of Normal Mucosa against Acid and Peptic Injury Three basic levels of defense underlie the remarkable ability of normal gastroduodenal mucosa to resist injury from the . . .
Supported in part by the Medical Research Service of the Department of Veterans Affairs and by grants (DK 19984 and DK 30444) from the National Institute of Diabetes and Digestive and Kidney Diseases.
Source Information
From the UCLA School of Medicine and the Wadsworth Veterans Affairs Hospital Center, Los Angeles. Address reprint requests to Dr. Soll at the Center for Ulcer Research and Education, Bldg. 115, Rm. 203, Wadsworth Veterans Affairs Hospital Center, Los Angeles, CA 90073.
Operative management of intraabdominal infections still rests on the principles of elimination of focus, reduction of contamination of the peritoneal cavity, and treatment of residual infection. To control the source of contamination from a perforated viscus primary closure, exclusion or resection may be considered with respect to the severity of peritonitis and to the underlying disease. The principle of "peritoneal toilet" with complementary use of systemic and/or local antibiotics is generally accepted even if the value of aggressive debridement is still debated controversely. For the treatment of residual and the prevention of recurrent infection, closed and open lavage techniques, the left-open abdomen, and planned relaparotomy represent the major approaches in severe generalized peritonitis when the infectious focus might not be securely controlled. The values and disadvantages of different regimens are discussed, additional measures are briefly described, and an outlook on areas of further research is given.
The thesis of this paper is that gastropathy associated with nonsteroidal antiinflammatory drugs (NSAIDs) is the most frequent and, in aggregate, the most severe drug side effect in the United States. This work is based on a consecutive series of 2400 patients with rheumatoid arthritis followed prospectively for an average of 3.5 yr by ARAMIS, the American Rheumatism Association Medical Information System. We present a preliminary exploration of the magnitude of the problem, the population at risk, and the patients within that population who are at particularly high risk. Patients on NSAIDs had a hazard ratio for gastrointestinal (GI) hospitalization that was 6.45 times that of patients not on NSAIDs. Characteristically, high-risk patients for GI hospitalization and GI death are older, have had previous upper abdominal pain, have previously stopped NSAIDs for GI side effects, and have previously used antacids or H2-receptor antagonists for GI side effects. They also are frequently on corticosteroids. In contrast, patients attributing relatively minor symptoms to the drug tend to be younger and more frequently female. Our preliminary analysis is univariate and, as these variables are interdependent, firm conclusions regarding the relative importance of these risk factors will require reevaluating our data base as it is expanded using multivariate analysis. The syndrome of NSAID-associated gastropathy can be estimated to account for at least 2600 deaths and 20,000 hospitalizations each year in patients with rheumatoid arthritis alone.
A nonvirulent strain of E. coli, type K12F-, that was labelled with chromium-51 was injected intraperitoneally. The thoracic duct was cannulated in the left side of the neck. Dogs were randomly divided into two groups. In Group A, six dogs were ventilated with a mechanical ventilator for 1 hour. They were then ventilated with PEEP (expiratory limb of the nonrebreathing system 10 cm below water level) for 1 hour, and finally ventilated without PEEP for another 30 minutes. In Group B, five dogs were initially ventilated with PEEP in the same manner employed in Group A for 1 hour, then were ventilated without PEEP for 1 hour, and finally were again ventilated with 10 cm PEEP for 30 minutes. Thoracic duct lymph was collected in 10 minute aliquots throughout the experiment.In Group A, when PEEP was instituted after a period of mechanical ventilation, there was significant diminution in the rate of lymph flow, but no significant change in bacterial clearance. When PEEP was discontinued, both lymph flow rate and bacterial clearance increased significantly. In Group B, when PEEP was removed, both lymph flow rate and bacterial clearance increased significantly. When PEEP was reinstituted, the rate of lymph flow significantly decreased, but the change in bacterial clearance was not significant.PEEP may exert a deleterious effect on the clearance of bacteria and particulate debris from the peritoneal cavity through the thoracic lymphatic vessels and should be used with caution in patients with abdominal sepsis.
MD-The Appendix in Sabiston Text Book of Surgery-18 th Edition Townsend
- John Maa
- Kimberly S Md
- Kirk Wood
John Maa, MD, Kimberly S.Kirk wood, MD-The Appendix in Sabiston Text Book of Surgery-18 th Edition Townsend, 2009, Volume 2 18 th edition Townsend, 2009, Volume 2,Pages
1333 -1345.
Department of General Surgery, Katuri Medical College & Hospital
- Professor
Professor, Department of General
Surgery, Katuri Medical College &
Hospital, Guntur.