domenica 15 aprile 2012

A retropritoneal abscess

Charity got an intrauterine fetal death at term in January 2012. She delivered a macerated still birth apparently without complications. She was therefore discharged with a short course of amoxyl in order to prevent puerperal sepsis.
Unfortunately she was admitted again a month later with symptoms and signs of acute peritonitis. She was taken to theatre where we have found a huge amount of pus in the peritoneum. The pus was sucked and the abdominal cavity washed. At this point it was possible to notice that pus was coming out of a laceration of the posterior parietal peritoneum, in front of the left psoas muscle. We thought of a psoas muscle abscess. We tried to probe the laceration with fingers, in order to break down the internal septations and to allow the pus to flow freely out of the abscess. A drainage tube was inserted into the abscess and another one into the peritoneal cavity. The recovery after operation was quick but the drainage tubes have continued to collect pus for about 2 weeks. Eventually we were able to remove the tubes and to discharge the patient.
Unfortunately a month later Charity was admitted again because the small wounds left by the drainage tubes had opened again and foul smelling pus was draining again out of them.
The patient was very sick and emaciated.
An U/S of the abdomen has ruled out any peritoneal involvement; therefore the pus was coming again from the extra-peritoneal space. Because we had not been able to find the exact origin of the pus with U/S we have referred our patient for CT scan abdomen.
The CT scan was very clear, as you can appreciate checking the attached photo: it was a big retro-renal abscess.
Charity was very anaemic and we had to transfuse 2 pints of blood before scheduling the operation again. Finally, when we reached an HB of 7 grams we decided to intervene.
The operation was an incision and drainage under general anesthesia, with patient laying on her right side. Much pus was collected and drainage tubes inserted. Now the patient is recovering very quickly.
It is quite difficult to understand why the patient, who is HIV negative, could get such a complicated disease. My opinion is that, during delivery of the still birth, already she had a puerperal sepsis. During the pushing efforts of delivery some septic embolus might have travelled through the blood stream reaching the retro-peritoneal space.
When she got the first peritonitis already it was because the retro-peritoneal abscess had burst into the peritoneal cavity. Our operation was partly unsuccessful because we did not realize that the origin of the pus was much higher than the laceration we saw (from behind the kidney). Therefore our debridement was incomplete.
Sometime after the operation the retro-renal abscess has found a new way out, creating a cutaneous sinus. But now we are confident that, having drained the retro0renal abscess, the patient will recover fully.
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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