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
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