domenica 8 gennaio 2012

Case report on massive rectorrhagia

An 18 year-old female patient has been admitted to our hospital for massive bleeding from the anus.
The patient was passing fresh blood and clots without any stool.
The general conditions were poor with an HB of 4 grams.
The first step of out treatment has been to stabilize the haemodynamic conditions with IV fluids and blood transfusion.
The first hypothesis was about a Shistosomiasis (Shistosoma Mansoni is actually prevalent in Tharaka); but the abdomen of the young lady was clearly peritonitic with a big mass below the umbilicus. The intestinal sounds were absent, and apart from blood she had not passed stool for the last three days.
A U/S has been performed in emergency and the picture was confusing: there was no free fluid in the abdominal cavity, but there were coils of enlarged and immobile intestinal loops.
After U/S I have decided on digital rectal examination: the examining finger was reaching a kind of wall at about 5 cm from the anus. It was not a mass; rather it was looking like oedematous mucosa covered with mucus.
The two findings together have made me suspect a sigmoid volvolus.
Therefore we decided for emergency laparatomy.
The patient was intubated and given general anaesthesia with relaxation. Opening the abdominal cavity we have found a situation much worse than expected: in fact a very thick omentum was covering a completely coiled intestine. The adhesions involved the whole of the gut from duodenum up to rectum.
We started a difficult and lengthy job of adhesion release. The procedure has been very difficult around the sigmoid and the colon, but it has been rather easy at the level of the small intestine.
While continuing the operation we have not found any intestinal perforation although the appendix was covered with fibrin and we decided to remove it.
In the Douglas pouch there was plenty of pus and necrotic debris, probably imprisoned there by the omentum: the material collected was foul smelling, like something quite old. The uterus was looking in a terrible shape: nearly necrotic and bluish in colour.
Both tubes were enlarged and bumpy like in pyosalpinix and their colour was no different from the one of the uterus.
 We therefore decided that the patient might have got a pelvi-peritonitis secondary to PID. The peritonitis has later generalized. The progressive coiling of the intestinal loops has possibly created a condition of capillary stasis and break-down, responsible of the rectorrhagia.
The operation ended without problems but the young patient died few hours afterwards.
We have felt very distressed by her demise because we believe that we have made the correct diagnosis and we have taken the right decision on emergency operation.
Probably the peritonitis has been long enough before admission to create a septicaemia which later has killed the lady.
Another possibility might be a pulmonary embolism possibly due to the manipulations of the pelvic organs during the operation.
Once again the doctor must admit that not always a correct diagnostic and therapeutic approach is enough to save a life.

Dr Giuseppe Gaido

Nessun commento:

Chaaria è un sogno da realizzare giorno per giorno.

Un luogo in cui vorrei che tutti i poveri e gli ammalati venissero accolti e curati.

Vorrei poter fare di più per questa gente, che non ha nulla e soffre per malattie facilmente curabili, se solo ci fossero i mezzi.

Vorrei smetterla di dire “vai altrove, perché non possiamo curarti”.

Anche perché andare altrove, qui, vuol dire aggiungere altra fatica, altro sudore, altro dolore, per uomini, donne e bambini che hanno già camminato per giorni interi.

E poi, andare dove?

Gli ospedali pubblici hanno poche medicine, quelli privati sono troppo costosi.

Ecco perché penso, ostinatamente, che il nostro ospedale sia un segno di speranza per questa gente. Non ci sarà tutto, ma facciamo il possibile. Anzi, l’impossibile.

Quello che mi muove, che ci muove, è la carità verso l’altro, verso tutti. Nessuno escluso.

Gesù ci ha detto di essere presenti nel più piccolo e nel più diseredato.

Questo è quello che facciamo, ogni giorno.

Fratel Beppe Gaido

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