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1.  INTESTINAL OBSTRUCTION COMPLICATING ACUTE PERFORATIVE APPENDICITIS 
California Medicine  1957;87(4):231-236.
Upon preoperative diagnosis of acute small bowel obstruction, without an obvious cause, acute perforative appendicitis must be considered. Reevaluation of the history and careful reexamination of the physical findings with that diagnosis in mind should be carried out. If appendiceal disease is likely, maximum antibiotic therapy must be begun immediately along with the administration of fluids, electrolytes and other corrective therapy. A mercury-weighted small bowel tube should be inserted and every effort made to advance it into the small bowel before operation. Operative treatment should be restricted to the least possible. A McBurney incision is best unless wider operation is indicated. If an abscess is present, drainage alone may be the procedure of choice. Severely distended and decompensated small bowel must be decompressed, for if not relieved it can be the cause of death in acute perforative appendicitis. Decompression may be accomplished either by small bowel intubation with continuous suction or by enterotomy and aspiration. If not relieved, small bowel distention will be the mechanism responsible for death in a large percentage of patients with acute perforative appendicitis.
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PMCID: PMC1512160  PMID: 13460738
2.  Spectrum of Perforation Peritonitis in Delhi: 77 Cases Experience 
The Indian Journal of Surgery  2012;75(2):133-137.
Perforation peritonitis is the most common surgical emergency encountered by surgeons all over the world as well in India. The spectrum of etiology of perforation peritonitis in tropical countries continues to differ from its western counterpart. This study was conducted at Hindu Rao Hospital, Municipal Corporation of Delhi, New Delhi, India, designed to highlight the spectrum of perforation peritonitis in the eastern countries and to improve its outcome. This prospective study included 77 consecutive patients of perforation peritonitis studied in terms of clinical presentations, causes, site of perforation, surgical treatment, postoperative complications, and mortality at Hindu Rao Hospital, Delhi, from March 1, 2011 to December 1, 2011, over a period of 8 months. All patients were resuscitated and underwent emergency exploratory laparotomy. On laparotomy cause of perforation peritonitis was found and controlled. The most common cause of perforation peritonitis noticed in our series was perforated duodenal ulcer (26.4 %) and ileal typhoid perforation (26.4 %), each followed by small bowel tuberculosis (10.3 %) and stomach perforation (9.2 %), perforation due to acute appendicitis (5 %). The highest number of perforations was seen in ileum (39.1 %), duodenum (26.4 %), stomach (11.5 %), appendix (3.5 %), jejunum (4.6 %), and colon (3.5 %). Overall mortality was 13 %. The spectrum of perforation peritonitis in India continuously differs from western countries. The highest number of perforations was noticed in the upper part of the gastrointestinal tract as compared to the western countries where the perforations seen mostly in the distal part. The most common cause of perforation peritonitis was perforated duodenal ulcer and small bowel typhoid perforation followed by typhoid perforation. Large bowel perforations and malignant perforations were least common in our setup.
doi:10.1007/s12262-012-0609-2
PMCID: PMC3644151  PMID: 24426408
Exploratory laparotomy; Emergency surgery; Perforation peritonitis; Primary repair; Stomas; Resection and anastomosis
3.  Spectrum of perforation peritonitis in Pakistan: 300 cases Eastern experience 
Background
Perforation peritonitis is the most common surgical emergency encountered by the surgeons all over the world as well in Pakistan. The spectrum of etiology of perforation peritonitis in tropical countries continues to differ from its western counter part. This study was conducted at Dow University of health sciences and Civil Hospital Karachi (DUHS & CHK) Pakistan, designed to highlight the spectrum of perforation peritonitis in the East and to improve its outcome.
Methods
A prospective study includes three hundred consecutive patients of perforation peritonitis studied in terms of clinical presentations, Causes, site of perforation, surgical treatment, post operative complications and mortality, at (DUHS&CHK) Pakistan, from 1st September 2005 – 1st March 2008, over a period of two and half years. All patients were resuscitated underwent emergency exploratory laparotomy. On laparotomy cause of perforation peritonitis was found and controlled.
Results
The most common cause of perforation peritonitis noticed in our series was acid peptic disease 45%, perforated duodenal ulcer (43.6%) and gastric ulcer 1.3%. followed by small bowel tuberculosis (21%) and typhoid (17%). large bowel perforation due to tuberculosis 5%, malignancy 2.6% and volvulus 0.3%. Perforation due to acute appendicitis (5%). Highest number of perforations has seen in the duodenum 43.6%, ileum37.6%, and colon 8%, appendix 5%, jejunum 3.3%, and stomach 2.3%. Overall mortality was (10.6%).
Conclusion
The spectrum of perforation peritonitis in Pakistan continuously differs from western country. Highest number of perforations noticed in the upper part of the gastrointestinal tract as compared to the western countries where the perforations seen mostly in the distal part. Most common cause of perforation peritonitis is perforated duodenal ulcer, followed by small bowel tuberculosis and typhoid perforation. Majority of the large bowel perforations are also tubercular. Malignant perforations are least common in our setup.
doi:10.1186/1749-7922-3-31
PMCID: PMC2614978  PMID: 18992164
4.  Appendiceal duplication with simultaneous acute appendicitis and appendicular perforation causing small bowel obstruction 
Acute appendicitis, as well as intestinal obstruction, is a common surgical emergencies. Both the conditions can present as an acute abdomen, however the diagnosis of acute appendicitis can be overlooked when it presents as a small bowel obstruction. Difficulties in correctly identifying the cause of pain can be hazardous to the patient and care needs to be taken in obtaining a prompt and accurate diagnosis enabling the most appropriate management. Appendiceal duplication although rare and difficult to diagnose preoperatively, should be checked while operating for appendicular pathology in order to avoid serious clinical and medicolegal implications.
We hereby report a case of appendiceal duplication presenting as small bowel obstruction with one appendix having acute appendicitis and the other one perforated in the middle third.
doi:10.1093/jscr/2011.2.3
PMCID: PMC3649207  PMID: 24950558
5.  Appendectomy and Resection of the Terminal Ileum with Secondary Severe Necrotic Changes in Acute Perforated Appendicitis 
Patient: Female, 19
Final Diagnosis: Acute perforated appendicitis • appendiceal abscess • secondary necrosis of the ileal wall
Symptoms: Right lower quadrant abdominal pain • fever
Medication: —
Clinical Procedure: Diagnostic laparoscopy • open drainage of an appendiceal abscess • appendectomy • ileal resection
Specialty: Surgery
Objective:
Management of emergency care
Background:
Resectional procedures for advanced and complicated appendicitis are performed infrequently. Their extent can vary: cecal resection, ileocecectomy, and even right hemicolectomy. We present a very rare case of appendectomy that was combined with partial ileal resection for severe necrotic changes and small perforation of the ileum.
Case Report:
A 19-year-old female patient was hospitalized with right iliac fossa pain and fever 10 days after the onset of symptoms. On laparoscopy, a large mass in a right iliac fossa was found. The ultrasound-guided drainage of the suspected appendiceal abscess was unavailable. After conversion using McBurney’s incision, acute perforated appendicitis was diagnosed. It was characterized by extension of severe necrotic changes onto the ileal wall and complicated by right iliac fossa abscess. A mass was bluntly divided, and a large amount of pus with fecaliths was discharged and evacuated. Removal of necrotic tissues from the ileal wall led to the appearance of a small defect in the bowel. A standard closure of this defect was considered as very unsafe due to a high risk of suture leakage or bowel stenosis. We perform a resection of the involved ileum combined with appendectomy and drainage/tamponade of an abscess cavity. Postoperative recovery was uneventful. The patient was discharged on the 15th day.
Conclusions:
In advanced appendicitis, the involved bowel resection can prevent possible complications (e.g., ileus, intestinal fistula, peritonitis, and intra-abdominal abscess). Our case may be the first report of an appendectomy combined with an ileal resection for advanced and complicated appendicitis.
doi:10.12659/AJCR.892471
PMCID: PMC4307687  PMID: 25618525
Abdominal Abscess; Appendicitis; Intestine, Small
6.  Time to Appendectomy and Risk of Perforation in Acute Appendicitis 
JAMA surgery  2014;149(8):837-844.
IMPORTANCE
In the traditional model of acute appendicitis, time is the major driver of disease progression; luminal obstruction leads inexorably to perforation without timely intervention. This perceived association has long guided clinical behavior related to the timing of appendectomy.
OBJECTIVE
To evaluate whether there is an association between time and perforation after patients present to the hospital.
DESIGN, SETTING, AND PARTICIPANTS
Using data from the Washington State Surgical Care and Outcomes Assessment Program (SCOAP), we evaluated patterns of perforation among patients (≥18 years) who underwent appendectomy from January 1, 2010, to December 31, 2011. Patients were treated at 52 diverse hospitals including urban tertiary centers, a university hospital, small community and rural hospitals, and hospitals within multi-institutional organizations.
MAIN OUTCOMES AND MEASURES
The main outcome of interest was perforation as diagnosed on final pathology reports. The main predictor of interest was elapsed time as measured between presentation to the hospital and operating room (OR) start time. The relationship between in-hospital time and perforation was adjusted for potential confounding using multivariate logistic regression. Additional predictors of interest included sex, age, number of comorbid conditions, race and/or ethnicity, insurance status, and hospital characteristics such as community type and appendectomy volume.
RESULTS
A total of 9048 adults underwent appendectomy (15.8% perforated). Mean time from presentation to OR was the same (8.6 hours) for patients with perforated and nonperforated appendicitis. In multivariate analysis, increasing time to OR was not a predictor of perforation, either as a continuous variable (odds ratio = 1.0 [95% CI, 0.99-1.01]) or when considered as a categorical variable (patients ordered by elapsed time and divided into deciles). Factors associated with perforation were male sex, increasing age, 3 or more comorbid conditions, and lack of insurance.
CONCLUSIONS AND RELEVANCE
There was no association between perforation and in-hospital time prior to surgery among adults treated with appendectomy. These findings may reflect selection of those at higher risk of perforation for earlier intervention or the effect of antibiotics begun at diagnosis but they are also consistent with the hypothesis that perforation is most often a prehospital occurrence and/or not strictly a time-dependent phenomenon. These findings may also guide decisions regarding personnel and resource allocation when considering timing of nonelective appendectomy.
doi:10.1001/jamasurg.2014.77
PMCID: PMC4160117  PMID: 24990687
7.  Jejunal perforation in gallstone ileus – a case series 
Introduction
Gallstone ileus is an uncommon complication of cholelithiasis but an established cause of mechanical bowel obstruction in the elderly. Perforation of the small intestine proximal to the obstructing gallstone is rare, and only a handful of cases have been reported. We present two cases of perforation of the jejunum in gallstone ileus, and remarkably in one case, the gallstone ileus caused perforation of a jejunal diverticulum and is to the best of our knowledge the first such case to be described.
Case presentations
Case 1
A 69 year old man presented with two days of vomiting and central abdominal pain. He underwent laparotomy for small bowel obstruction and was found to have a gallstone obstructing the mid-ileum. There was a 2 mm perforation in the anti-mesenteric border of the dilated proximal jejunum. The gallstone was removed and the perforated segment of jejunum was resected.
Case 2
A 68 year old man presented with a four day history of vomiting and central abdominal pain. Chest and abdominal radiography were unremarkable however a subsequent CT scan of the abdomen showed aerobilia. At laparotomy his distal ileum was found to be obstructed by an impacted gallstone and there was a perforated diverticulum on the mesenteric surface of the mid-jejunum. An enterolithotomy and resection of the perforated small bowel was performed.
Conclusion
Gallstone ileus remains a diagnostic challenge despite advances in imaging techniques, and pre-operative diagnosis is often delayed. Partly due to the elderly population it affects, gallstone ileus continues to have both high morbidity and mortality rates. On reviewing the literature, the most appropriate surgical intervention remains unclear.
Jejunal perforation in gallstone ileus is extremely rare. The cases described illustrate two quite different causes of perforation complicating gallstone ileus. In the first case, perforation was probably due to pressure necrosis caused by the gallstone. The second case was complicated by the presence of a perforated jejunal diverticulum, which was likely to have been secondary to the increased intra-luminal pressure proximal to the obstructing gallstone.
These cases should raise awareness of the complications associated with both gallstone ileus, and small bowel diverticula.
doi:10.1186/1752-1947-1-157
PMCID: PMC2222670  PMID: 18045463
8.  Acute mechanical bowel obstruction: Clinical presentation, etiology, management and outcome 
AIM: To identify and analyze the clinical presentation, management and outcome of patients with acute mechanical bowel obstruction along with the etiology of obstruction and the incidence and causes of bowel ischemia, necrosis, and perforation.
METHODS: This is a prospective observational study of all adult patients admitted with acute mechanical bowel obstruction between 2001 and 2002.
RESULTS: Of the 150 consecutive patients included in the study, 114 (76%) presented with small bowel and 36 (24%) with large bowel obstruction. Absence of passage of flatus (90%) and/or feces (80.6%) and abdominal distension (65.3%) were the most common symptoms and physical finding, respectively. Adhesions (64.8%), incarcerated hernias (14.8%), and large bowel cancer (13.4%) were the most frequent causes of obstruction. Eighty-eight patients (58.7%) were treated conservatively and 62 (41.3%) were operated (29 on the first day). Bowel ischemia was found in 21 cases (14%), necrosis in 14 (9.3%), and perforation in 8 (5.3%). Hernias, large bowel cancer, and adhesions were the most frequent causes of bowel ischemia (57.2%, 19.1%, 14.3%), necrosis (42.8%, 21.4%, 21.4%), and perforation (50%, 25%, 25%). A significantly higher risk of strangulation was noticed in incarcerated hernias than all the other obstruction causes.
CONCLUSION: Absence of passage of flatus and/or feces and abdominal distension are the most common symptoms and physical finding of patients with acute mechanical bowel obstruction, respectively. Adhesions, hernias, and large bowel cancer are the most common causes of obstruction, as well as of bowel ischemia, necrosis, and perforation. Although an important proportion of these patients can be nonoperatively treated, a substantial portion requires immediate operation. Great caution should be taken for the treatment of these patients since the incidence of bowel ischemia, necrosis, and perforation is significantly high.
doi:10.3748/wjg.v13.i3.432
PMCID: PMC4065900  PMID: 17230614
Acute mechanical bowel obstruction; Clinical presentation; Etiology; Management; Outcome
9.  Meconium obstruction in absence of cystic fibrosis in low birth weight infants: an emerging challenge from increasing survival 
Background
Meconium abnormalities are characterized by a wide spectrum of severity, from the meconium plug syndrome to the complicated meconium ileus associated with cystic fibrosis. Meconium Related Ileus in absence of Cystic Fibrosis includes a combination of highly viscid meconium and poor intestinal motility, low grade obstruction, benign systemic and abdominal examination, distended loops without air fluid levels. Associated risk factors are severe prematurity and low birth weight, Caesarean delivery, Maternal MgSO4 therapy, maternal diabetes. In the last 20 yrs a new specific type of these meconium related obstructions has been described in premature neonates with low birth weight. Its incidence has shown to increase while its management continues to be challenging and controversial for the risk of complicated obstruction and perforation.
Materials and methods
Among 55 newborns admitted between 1992-2008 with Meconium Related Ileus as final diagnosis, data about Low Birth Weight infants (LBW < 1500 g) were extracted and compared to those of patients ≥ 1500 g. Hischsprung's Diseases and Cystic Fibrosis were excluded by rectal biopsy and genetic probe before discharge. A softening enema with Gastrografin was the first option whenever overt perforation was not present. Temporary stoma or trans appendiceal bowel irrigation were elected after unsuccessful enema while prompt surgical exploration was performed in perforated cases. NEC was excluded in all operated cases. Data collected were perinatal history and neonatal clinical data, radiological signs, clinical course and complications, management and outcome.
Results
30 cases with BW ≥ 1500 g had an M/F ratio16/14, Mean B.W. 3052 g, Mean G.A. 37 w Caesarean section rate 40%. There were 10 meconium plug syndrome, 4 small left colon syndromes, and 16 meconium ileus without Cystic Fibrosis. Five cases were born at our institution (inborn) versus 25 referred after a mean of 2, 4 Days (1-7) after birth in another Hospital (outborn). They were managed, after a Gastrografin enema with 90% success rate, by 1 temporary Ileostomy and 2 trans appendiceal irrigation. 25 cases with BW< 1500 g (LBW) had M/F ratio 11/14, Mean B.W. 818 g, Mean G.A. 27 w, Caesarean section rate 70%, assisted ventilation 16/25. There were 8 inborn and 17 outborn. Gastrografin enema was successful in 6 out 8 inborn infants only, all referred within one week from birth. There were 12 perforations mainly among late referred LBW outborn.
Conclusions
Meconium Related Ileus without Cystic Fibrosis responds to conservative management and softening enema in most of mature infants. In LBW clinical course is initially benign but as any long standing bowel obstruction management may present particular challenges. Clinical and plain radiographic criteria are reliable for making diagnosis and testing for Cystic Fibrosis may not be indicated. Enema may be resolutive when performed in a proper environment. Perforated cases may be confused with NEC which is excluded by clinical history, no signs of sepsis, lab signs missing, abdominal signs missing, typical radiological signs missing. The higher complication rate is recorded among cases delivered and initially managed in Neonatal Units without co-located Surgical Facilities. Early diagnosis and aggressive medical therapy may lead to higher success rate and help avoiding surgical interventions. Surgical therapy in uncomplicated cases, unresponsive to medical management, should be minimally aggressive.
doi:10.1186/1824-7288-37-55
PMCID: PMC3262744  PMID: 22082231
10.  Appendicitis 
BMJ Clinical Evidence  2011;2011:0408.
Introduction
Appendicitis is an acute inflammation of the appendix that can lead to an abscess, ileus, peritonitis, or death. Appendicitis is the most common abdominal surgical emergency, with a lifetime risk of approximately 7% to 9% in the USA. Mortality from acute appendicitis is less than 0.3%, but rises to 1.7% after perforation.
Methods and outcomes
We conducted a systematic review and aimed to answer the following clinical question: What are the effects of treatments for acute appendicitis? We searched: Medline, Embase, The Cochrane Library, and other important databases up to February 2010 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
Results
We found 16 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
Conclusions
In this systematic review we present information relating to the effectiveness and safety of the following interventions: antibiotics, laparoscopic surgery, ligation, open surgery, stump inversion, and surgery.
Key Points
The incidence of acute appendicitis is falling, although the reasons are unclear. Appendicitis is the most common abdominal surgical emergency, with a lifetime risk of approximately 7% to 9% in the USA.Potential causes of appendicitis include faecoliths, lymphoid hyperplasia, fibrous bands, foreign bodies, and caecal carcinoma, all of which can lead to obstruction of the appendix lumen.Mortality from acute appendicitis is <0.3%, but rises to 1.7% after perforation.
Spontaneous resolution of acute appendicitis has been reported in at least 10% of episodes.
Very limited evidence suggests that conservative treatment of acute appendicitis with antibiotics may reduce pain and morphine consumption, but that one third of people are likely to be readmitted with acute appendicitis requiring surgery within 1 year.
Standard treatment for acute appendicitis is appendicectomy. Clinical trials to compare surgery with no treatment would be considered unethical, and have not been done.There is good evidence that laparoscopic surgery in adults reduces wound infections, postoperative pain, duration of hospital stay, and time off work compared with open surgery, but increases the risk of intra-abdominal abscesses.Limited evidence suggests that laparoscopic surgery in children may reduce wound infections and duration of hospital stay compared with open surgery, but it has not been shown to reduce other complications.There is some evidence to suggest that stapling reduces operative time compared with endoloops, but no reliable evidence to suggest that it reduces other complications.We don't know how natural orifice surgery compares with laparoscopic surgery, as we found no RCTs.There is limited evidence to suggest that stump inversion has an increased rate of wound infection compared with simple ligation, and no difference in rate of intra-abdominal abscess formation.
The most common complication of appendicectomy is wound infection, with intra-abdominal abscess formation less common. Treatment with surgery plus antibiotics reduces wound infections and intra-abdominal abscesses compared with surgery alone in adults with simple or complicated appendicitis.However, in children, the benefit of antibiotics may be limited to those with complicated appendicitis.
PMCID: PMC3275312  PMID: 21477397
11.  Appendicitis 
BMJ Clinical Evidence  2007;2007:0408.
Introduction
Potential causes of appendicitis include faecoliths, lymphoid hyperplasia, and caecal carcinoma, all of which can lead to obstruction of the appendix lumen. The lifetime risk is approximately 7-9% in the USA, making appendicectomy the most common abdominal surgical emergency. Mortality from acute appendicitis is less than 0.3%, but rises to 1.7% after perforation.
Methods and outcomes
We conducted a systematic review and aimed to answer the following clinical question: What are the effects of treatments for acute appendicitis? We searched: Medline, Embase, The Cochrane Library and other important databases up to November 2006 (BMJ Clinical evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
Results
We found 10 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
Conclusions
In this systematic review we present information relating to the effectiveness and safety of the following interventions: antibiotics, laparoscopic surgery, ligation, open surgery, stump inversion, surgery.
Key Points
The incidence of acute appendicitis is falling, although the reasons are unclear. The lifetime risk is approximately 7-9% in the USA, making appendicectomy the most common abdominal surgical emergency.Potential causes of appendicitis include faecoliths, lymphoid hyperplasia, and caecal carcinoma, all of which can lead to obstruction of the appendix lumen.Mortality from acute appendicitis is less than 0.3%, but rises to 1.7% after perforation.
Spontaneous resolution of acute appendicitis has been reported in at least 8% of episodes. Very limited evidence suggests that conservative treatment of acute appendicitis with antibiotics may reduce pain and morphine consumption, but that a third of people are likely to be readmitted with acute appendicitis requiring surgery within 1 year.
Standard treatment for acute appendicitis is appendicectomy. Clinical trials to compare surgery with no surgery would be considered unethical, and have not been done.There is some evidence that laparoscopic appendicectomy in adults reduces wound infections, postoperative pain, duration of hospital stay, and time off work compared with open surgery, but may increase the risk of intra-abdominal abscesses.Limited evidence suggests that laparoscopic surgery in children may reduce wound infections and duration of hospital stay compared with open surgery, but it has not been shown to reduce other complications.
The most common complication of appendicectomy is wound infection, with intra-abdominal abscess formation less common. Treatment with surgery plus antibiotics reduces wound infections and intra-abdominal abscesses compared with surgery alone in adults with simple or complicated appendicitis.However, in children, the benefit of antibiotics may be limited to those with complicated appendicitis.
PMCID: PMC2943782  PMID: 19454096
12.  Appendiceal tie syndrome: A very rare complication of a common disease 
Acute appendicitis is the most common surgical emergency that we encounter. Adynamic Intestinal obstruction due to appendicitis or its complication may be seen time and often. Mechanical obstruction because of appendicitis is uncommon and even rarer for a closed loop obstruction to occur. Although it was described as early as 1901, very few cases have been reported. We report the case of a 20 years male who presented with generalized colicky pain abdomen, abdominal distension, vomiting and obstipation for three to four days. Vital signs were stable. His abdomen was distended and peritonitic, especially in the right iliac fossa. Rest of the physical examination was unremarkable. Blood tests were normal except for leucocytosis with neutrophilia. An abdominal X-ray finding was indicating a small bowel obstruction. A midline laparotomy was performed. On intraoperative examination, distended loops of small bowel from the jejunum to the distal ileum was observed, and a constricting ring around the terminal ileum created by a phlegmonous appendicitis with its tip adherent to the root of mesentery was found, obstructing an edematous loop of small bowel without signs of ischemia. As the bowel was viable simple appendectomy was done. Postoperatively, he had an uneventful recovery and was discharged after 3 d.
doi:10.4240/wjgs.v7.i4.67
PMCID: PMC4390893  PMID: 25914785
Appendicitis; Appendicular band; Intestinal obstruction; Mechanical small bowel obstruction; Closed loop obstruction
13.  An Observational Study of the Etiology, clinical presentation and outcomes associated with peritonitis in Lilongwe, Malawi 
Introduction
Peritonitis is a life-threatening condition with a multitude of etiologies that can vary with geographic location. The aims of this study were to elucidate the etiology, clinical presentation and outcomes associated with peritonitis in Lilongwe, Malawi.
Methods
All patients admitted to Kamuzu Central Hospital (KCH) who underwent an operation for treatment of peritonitis during the calendar year 2008 were eligible. Peritonitis was defined as abdominal rigidity, rebound tenderness, and/or guarding in one or more abdominal quadrants. Subjects were identified from a review of the medical records for all patients admitted to the adult general surgical ward and the operative log book. Those who met the definition of peritonitis and underwent celiotomy were included.
Results
190 subjects were identified. The most common etiologies were appendicitis (22%), intestinal volvulus (17%), perforated peptic ulcer (11%) and small bowel perforation (11%). The overall mortality rate associated with peritonitis was 15%, with the highest mortality rates observed in solid organ rupture (35%), perforated peptic ulcer (33%), primary/idiopathic peritonitis (27%), tubo-ovarian abscess (20%) and small bowel perforation (15%). Factors associated with death included abdominal rigidity, generalized (versus localized) peritonitis, hypotension, tachycardia and anemia (p < 0.05). Age, gender, symptoms (obstipation, vomiting) and symptom duration, tachypnea, abnormal temperature, leukocytosis, hemoconcentration, thrombocytopenia and thrombocytosis were not associated with mortality (p = NS).
Conclusions
There are several signs and laboratory findings predictive of poor outcome in Malawian patients with peritonitis. Tachycardia, hypotension, anemia, abdominal rigidity and generalized peritonitis are the most predictive of death (P < 0.05 for each). Similar to studies from other African countries, in our population the most common cause of peritonitis was appendicitis, and the overall mortality rate among all patients with peritonitis was 15%. Identified geographical differences included intestinal volvulus, rare in the US but the 2nd most common cause of peritonitis in Malawi and gallbladder disease, common in Ethiopia but not observed in Malawi. Future research should investigate whether correction of factors associated with mortality might improve outcomes.
doi:10.1186/1749-7922-6-37
PMCID: PMC3223493  PMID: 22067899
14.  The case of the forgotten toothbrush 
INTRODUCTION
Although foreign body ingestion is relatively common, toothbrush swallowing is rare. A diagnosis of small-bowel perforation, caused by a sharp or pointed foreign body, is rarely made preoperatively because the clinical symptoms are usually nonspecific and can mimic other surgical conditions, such as appendicitis and diverticulitis.
PRESENTATION OF CASE
We report a case of a swallowed toothbrush which passed past the pylorus and perforated the terminal ileum. The patient however presented with a fluctuant mass in the left iliac fossa, pyrexia and generalised tenderness mimicking a diverticular abscess.
DISCUSSION
Ingestion of a foreign body is commonly encountered in the clinic among children, adults with intellectual impairment, psychiatric illness or alcoholism, and dental prosthetic-wearing elderly subjects. However, toothbrush swallowing is rare, with only approximately 40 reported cases.
CONCLUSION
Bowel perforation by foreign bodies can mimic acute appendicitis and should be considered in differential diagnoses. Clinically, patients often do not recall ingesting the foreign body, which makes the clinical diagnosis more challenging, and a correct diagnosis is frequently delayed. Several radiological investigations, such as small-bowel series, ultrasonography, and computed tomography scans, may lead to the correct diagnosis, but in most patients, the diagnosis is not confirmed until the surgical intervention has been performed.
doi:10.1016/j.ijscr.2012.01.008
PMCID: PMC3316764  PMID: 22406347
Toothbrush ingestion; Small bowel perforation
15.  Aberrant Mesoappendix Vasculature: A Unique Cause of Partial Small Bowel Obstruction 
This report describes a case of small bowel obstruction caused by an aberrant intraabdominal vessel.
Small bowel obstructions are most frequently caused by hernias or adhesive bands. However, there have been several rare reported cases of mechanical small bowel obstructions caused by loops of bowel or vascular bands. We describe a case of a 30-year-old woman with a clinical presentation suggestive of appendicitis. Laparoscopic evaluation showed an aberrant vessel looping around the small bowel extending from the lateral anterior abdominal wall to the mesoappendix, resulting in a partial small bowel obstruction. We review the literature relating to bowel obstructions resulting from bowel knots and vascular bands. To our knowledge, this is the first reported case of a small bowel obstruction caused by an aberrant intraabdominal vessel.
doi:10.4293/108680810X12785289144881
PMCID: PMC3043588  PMID: 20932389
Mesoappendix; Intestinal obstruction/etiology; Mesentery/abnormalities; Appendix/abnormalities
16.  Spectral analysis of bowel sounds in intestinal obstruction using an electronic stethoscope 
AIM: To determine the value of bowel sounds analysis using an electronic stethoscope to support a clinical diagnosis of intestinal obstruction.
METHODS: Subjects were patients who presented with a diagnosis of possible intestinal obstruction based on symptoms, signs, and radiological findings. A 3M™ Littmann® Model 4100 electronic stethoscope was used in this study. With the patients lying supine, six 8-second recordings of bowel sounds were taken from each patient from the lower abdomen. The recordings were analysed for sound duration, sound-to-sound interval, dominant frequency, and peak frequency. Clinical and radiological data were reviewed and the patients were classified as having either acute, subacute, or no bowel obstruction. Comparison of bowel sound characteristics was made between these subgroups of patients. In the presence of an obstruction, the site of obstruction was identified and bowel calibre was also measured to correlate with bowel sounds.
RESULTS: A total of 71 patients were studied during the period July 2009 to January 2011. Forty patients had acute bowel obstruction (27 small bowel obstruction and 13 large bowel obstruction), 11 had subacute bowel obstruction (eight in the small bowel and three in large bowel) and 20 had no bowel obstruction (diagnoses of other conditions were made). Twenty-five patients received surgical intervention (35.2%) during the same admission for acute abdominal conditions. A total of 426 recordings were made and 420 recordings were used for analysis. There was no significant difference in sound-to-sound interval, dominant frequency, and peak frequency among patients with acute bowel obstruction, subacute bowel obstruction, and no bowel obstruction. In acute large bowel obstruction, the sound duration was significantly longer (median 0.81 s vs 0.55 s, P = 0.021) and the dominant frequency was significantly higher (median 440 Hz vs 288 Hz, P = 0.003) when compared to acute small bowel obstruction. No significant difference was seen between acute large bowel obstruction and large bowel pseudo-obstruction. For patients with small bowel obstruction, the sound-to-sound interval was significantly longer in those who subsequently underwent surgery compared with those treated non-operatively (median 1.29 s vs 0.63 s, P < 0.001). There was no correlation between bowel calibre and bowel sound characteristics in both acute small bowel obstruction and acute large bowel obstruction.
CONCLUSION: Auscultation of bowel sounds is non-specific for diagnosing bowel obstruction. Differences in sound characteristics between large bowel and small bowel obstruction may help determine the likely site of obstruction.
doi:10.3748/wjg.v18.i33.4585
PMCID: PMC3435785  PMID: 22969233
Bowel sounds; Intestinal obstruction; Spectral analysis; Electronic stethoscope
17.  Capsule impaction presenting as acute small bowel perforation: a case series 
Introduction
Perforation caused by capsule endoscopy impaction is extremely rare and, at present, only five cases of perforation from capsule endoscopy impaction are reported in the literature.
Case presentation
We report here two cases of patients with undiagnosed small bowel stenosis presenting with acute perforation after capsule endoscopy. Strictures in the small bowel were likely the inciting mechanism leading to acute small bowel obstruction and subsequent distension and perforation above the capsule in the area of maximal serosal tension.
Case 1 was a 55-year-old Italian woman who underwent capsule endoscopy because of recurrent postprandial cramping pain and iron deficiency anemia, in the setting of negative imaging studies including an abdominal ultrasound, upper endoscopy, colonoscopy and small bowel follow-through radiograph. She developed a symptomatic bowel obstruction approximately 36 hours after ingestion of the capsule. Emergent surgery was performed to remove the capsule, which was impacted at a stenosis due to a previously undiagnosed ileal adenocarcinoma, leading to perforation.
Case 2 was a 60-year-old Italian man with recurrent episodes of abdominal pain and diarrhea who underwent capsule endoscopy after conventional modalities, including comprehensive blood and stool studies, computed tomography, an abdominal ultrasound, upper endoscopy, colonoscopy, barium enema and small bowel follow-through, were not diagnostic. Our patient developed abdominal distension, acute periumbilical pain, fever and leukocytosis 20 hours after capsule ingestion. Emergent surgery was performed to remove the capsule, which was impacted at a previously undiagnosed ileal Crohn’s stricture, leading to perforation.
Conclusions
The present report shows that, although the risk of acute complication is very low, the patient should be informed of the risks involved in capsule endoscopy, including the need for emergency surgical exploration.
doi:10.1186/1752-1947-6-121
PMCID: PMC3424159  PMID: 22554208
18.  Role of the faecolith in modern-day appendicitis 
Introduction
The prevailing view on appendicitis is that the main aetiology is obstruction owing to faecoliths in adults and lymphoid hyperplasia in children. Faecoliths on imaging studies are believed to correlate well with appendicitis.
Methods
A retrospective chart review was conducted of 1,014 emergency appendicectomy patients between 2001 and 2011. Faecolith prevalence in adult and paediatric appendicectomy specimens with and without perforation was studied. The sensitivity and positive predictive value (PPV) of computed tomography (CT) for identifying faecoliths in the pathology specimen were examined.
Results
Overall, faecoliths were found in 18.1% (178/986) of appendicitis specimens and 28.6% (8/28) of negative appendicectomies. Faecolith prevalence for positive cases was 29.9% (79/264) in paediatric patients and 13.7% (99/722) in adults (p<0.05). Faecolith prevalence was 39.4% in perforated appendicitis but only 14.6% in non-perforated appendicitis (p<0.05). In adults, faecolith prevalence was 27.5% in perforated appendicitis and 12.0% in non-perforated appendicitis (p<0.05) while in paediatric patients, it was 56.1% in perforated appendicitis and 22.7% in non-perforated appendicitis (p=0.00). Sensitivity and PPV of preoperative CT in identifying faecoliths on pathology were 53.1% (86/162) and 44.8% (86/192) respectively.
Conclusions
Faecolith prevalence is too low to consider the faecolith the most common cause of non-perforated appendicitis. Faecoliths are more prevalent in paediatric appendicitis than in adult appendicitis. Preoperative CT is an unreliable predictor of faecoliths in pathology specimens.
doi:10.1308/003588413X13511609954851
PMCID: PMC3964638  PMID: 23317728
Appendicitis; Faecoliths; Pathology; Computed tomography
19.  An unusual cause of small bowel obstruction caused by a Richter's-type hernia into the urinary bladder 
INTRODUCTION
The authors present an unusual case of small bowel obstruction in a 62-year-old man.
PRESENTATION OF CASE
A 62-year-old man with a background of transitional cell carcinoma (TCC) of the bladder presented to the emergency department with abdominal pain, distension, vomiting and had not opened his bowels for three days. 3 weeks previously he had a repeat Transurtheral resection of bladder tumour (TURBT), during which there was an iatrogenic perforation of the bladder. A CT scan of the abdomen and pelvis revealed small bowel obstruction but did not identify a cause. At laparotomy the cause of the obstruction was identified as a section of the small bowel that had partially herniated into the bladder, via the perforation. The defect was repaired and the patient made an uneventful recovery.
DISCUSSION
Herniation of the bowel into a defect in the bladder wall is a rare event with only 6 previous cases reported in the literature. It can cause signs and symptoms of bowel obstruction.
CONCLUSION
In patients with known bladder perforations who present with symptoms and signs of bowel obstruction, bowel herniation into the bladder should be considered. Early surgical intervention may be necessary if the patient is clinically unwell with appropriate symptoms and signs and imaging does not provide conclusive answer.
doi:10.1016/j.ijscr.2014.04.027
PMCID: PMC4064428  PMID: 24858979
Bowel obstruction; Bladder perforation; Internal hernia
20.  Perforated acute appendicitis resulting from appendiceal villous adenoma presenting with small bowel obstruction: a case report 
BMC Gastroenterology  2011;11:35.
Background
A villous adenoma is an extremely rare benign tumour in the appendix, in contrast to other benign appendiceal lesions. The clinical features are usually asymptomatic. Acute appendicitis is the most common complication with the lesion obstructing the orifice of the appendiceal lumen. Thus, a villous adenoma is usually found during surgical intervention for acute appendicitis. Mechanical obstruction induced by acute perforated appendicitis has been previously reported. Acute appendicitis caused by a villous adenoma presenting with acute intestinal obstruction has not been previously reported.
Case presentation
A 78-year-old woman presented to our Emergency Department with diffuse abdominal pain and tenderness. The abdominal plain film and computed tomography revealed an intestinal obstruction. After surgical intervention, the ruptured appendix was shown to be associated with intestinal obstruction. The post-operative pathologic diagnosis was an appendiceal villous adenoma.
Conclusions
This is the first report describing an appendiceal villous adenoma, which is an occasional cause of perforated acute appendicitis, presenting as a complete intestinal obstruction. We emphasize that in elderly patients without a surgical history, the occult cause of complete intestinal obstruction must be determined. If an appendiceal tumour is diagnosed, an intra-operative frozen section is suggested prior to selecting a suitable method of surgical intervention.
doi:10.1186/1471-230X-11-35
PMCID: PMC3094313  PMID: 21477328
21.  Laparoscopic port site Richter's hernia – An important lesson learnt 
Introduction
We report a case of small bowel obstruction with strangulation caused by a port site hernia following a laparoscopic appendicectomy and the successful management of the problem by employing a laparoscopy assisted technique. The aim of this report is to emphasize the importance of fascial closures of trocar sites in order to significantly decrease postoperative morbidity.
Case report
A 31 years old female presented with a classic clinical picture of acute appendicitis. She underwent an uneventful laparoscopic appendicectomy. A 12 mm trocar was used at the umbilical port. On Postoperative day three, the patient developed abdominal distension, crampy abdominal pain, nausea and bilious vomiting. Her white cell count increased to 16,500/mm3, and CRP was 145. X-ray abdomen showed dilated small bowel with multiple air fluid levels. CT scan showed a herniated loop of small bowel into the trocar site with small bowel obstruction. Laparoscopy was done to confirm the Richter's hernia into trocar site with small bowel obstruction. The bowel loop could not be reduced laparoscopically. Limited exploration of the trocar site confirmed findings with necrosis of the antimesenteric portion of the small bowel. A limited bowel resection and anastomosis was performed. The patient had an uneventful recovery.
Conclusion
Most port site hernias present within 10 days of the primary procedures, delayed hernias have been reported. CT scan is a helpful adjunct to differentiate port site hematoma from incarcerated small bowel. The knowledge of such a complication and its early diagnosis are important to avoid complications.
doi:10.1016/j.ijscr.2010.11.002
PMCID: PMC3199732  PMID: 22096675
Laparoscopy; Complications; Port site; Hernia
22.  Laparoscopic Appendectomy in Children 
Background and Objectives:
The advantages of laparoscopic appendectomy over open appendectomy have not yet been clearly demonstrated. The present study evaluated our early experience with laparoscopic appendectomy in children, in terms of its safety, effectiveness, technical difficulties, and economics.
Methods:
We reviewed the records of 50 cases involving laparoscopic appendectomy performed at our affiliated institutions between September, 1994, and September, 1996. Patient age ranged from 6 to 18 years (mean, 14 years). Thirty-two patients had acute nonperforated appendicitis, six had perforated appendicitis, two had fibrosis of the appendix, and ten had a histologically normal appendix.
Results:
In five patients the laparoscopic procedures were converted to open appendectomies because of technical difficulties. There were postoperative complications in four patients: one incomplete appendectomy which subsequently required an open appendectomy for completion, one pelvic abscess, one bowel obstruction, and one minor wound infection.
Conclusions:
Laparoscopic appendectomy is a safe and effective procedure. It takes longer operative time than open appendectomy. Length of hospitalization and incidence of postoperative complications are equivalent to those of open appendectomy. Economic benefits are difficult to assess at present. In sum, we believe that with better training, surgical techniques and equipment, laparoscopic appendectomy will eventually become the surgical procedure of choice in appendicitis.
PMCID: PMC3015229  PMID: 9876644
Adolescence; Child; Appendectomy; Laparoscopy
23.  Meckel's Diverticulum with Small Bowel Obstruction Presenting as Appendicitis in a Pediatric Patient 
The authors suggest that the small bowel be assessed in all appendectomy cases for a pathological Meckel's diverticulum.
Background:
Meckel's diverticulum is a congenital anomaly resulting from incomplete obliteration of the omphalomesenteric duct. The incidence ranges from 0.3% to 2.5% with most patients being asymptomatic. In some cases, complications involving a Meckel's diverticulum may mimic other disease processes and obscure the clinical picture.
Methods:
This case presents an 8-year-old male with abdominal pain, nausea, and vomiting and an examination resembling appendicitis.
Results:
A CT scan revealed findings consistent with appendicitis with dilated loops of small bowel. During laparoscopic appendectomy, the appendix appeared unimpressive, and an inflamed Meckel's diverticulum was found with an adhesive band creating an internal hernia with small bowel obstruction. The diverticulum was resected after the appendix was removed.
Conclusion:
The incidence of an internal hernia with a Meckel's diverticulum is rare. A diseased Meckel's diverticulum can be overlooked in many cases, especially in those resembling appendicitis. It is recommended that the small bowel be assessed in all appendectomy cases for a pathological Meckel's diverticulum.
doi:10.4293/108680811X13176785204553
PMCID: PMC3340971  PMID: 22643517
Meckel's diverticulum; Appendicitis; Laparoscopic; Internal hernia; Omphalomesenteric duct; Small bowel obstruction
24.  Colonic metastases from small cell carcinoma of the lung presenting with an acute abdomen: A case report 
Introduction
Colonic metastases are rare, and usually secondary from malignant tumours of the stomach, breast, ovarian, cervix, kidney, lung, prostate, or skin. Around one third are asymptomatic or found only at autopsy.
Case Report
A middle-aged male smoker, who had a small cell carcinoma of the lung diagnosed two years previously and treated with radiotherapy and chemotherapy, was admitted to the emergency room with intense abdominal pain and constipation. With the suspicion of an acute appendicitis he was submitted to surgery. At laparotomy he was found to have a normal appendix but two hard colonic lesions: a mobile one in the right colon and the other fixing the sigmoid colon to the sacrum. A right hemicolectomy and a sigmoid loop colostomy were performed. Pathology showed those lesions to be colonic metastases from small cell carcinoma of the lung.
Discussion
Colonic secondaries are most frequently diagnosed in patients who have had a known primary tumour, and may present with bowel obstruction, lower gastrointestinal haemorrhage, gastrointestinal fistula, or intestinal perforation. Presentation with acute abdomen is rare, and survival is usually limited.
Conclusion
Colonic metastatic disease should be considered in any patient presenting with an acute abdomen and past history of lung malignancy.
doi:10.1016/j.ijscr.2015.02.035
PMCID: PMC4392334  PMID: 25732616
Colonic metastases; Acute abdomen; Lung cancer; Bowel obstruction
25.  Total laparoscopic management of large complicated jejunal diverticulum 
Jejunoileal diverticulae, also referred to as non-Meckelian diverticulae, are very uncommon. These diverticulae are considered to be acquired pulsion diverticulae and they mostly occur in older people. Their prevalence increases with age. About 80% of these diverticulae occur in jejunum and are usually multiple. Patients with jejunoileal diverticulae present with nonspecific symptoms. The clinical picture of a complicated jejunoileal diverticulae can be confused with other intra-abdominal acute conditions such as appendicitis, cholecystitis, perforated ulcer, etc. Nonmechanical or pseudoobstruction is related to the dyskinesia associated with this condition. The diagnosis is made by a small bowel contrast study, enteroclysis, endoscopy or computed tomography. A surgical approach is the best form of treatment for complicated jejunoileal diverticulae. Laparoscopy is very useful in diagnosing and treating this condition. The current report is about a patient who presented with recurrent subacute intestinal obstruction and was managed by laparoscopy.
doi:10.4103/0972-9941.59311
PMCID: PMC2843127  PMID: 20407572
Diagnostic laparoscopy; diverticulum; resection anastomosis

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