Perforated appendix is a serious surgical condition that carries a high morbidity. Antibiotic treatment is often started before the availability of bacteriological reports. The choice of antibiotics would depend on the bacteriology associated with perforated appendix. In a retrospective survey of the bacteriology of peritoneal pus obtained from cases of perforated appendix at the General Hospital, Kuala Lumpur, E. coli was found to be the most commonly encountered organism. This was followed in order of decreasing frequency by streptococci, Bacteroides species, Klebsiella-Enterobacter group and Pseudomonas aeruginosa. From the results of the antibiotic sensitivities an antibiotic regimen comprising of a combination of gentamicin, metronidazole and penicillin is recommended as appropriate chemotherapy in perforated appendix.
During the 10-year period 1974-1983, 68 patients with intraperitoneal haemorrhage as a result of the rupture of a corpus luteum were managed at the University Hospital, Kuala Lumpur, Malaysia. Most of the patients were aged between 18 and 35 years. In 63% of the patients the rupture occurred between the 14th and the 35th day of the menstrual cycle, and 10 patients had intraperitoneal bleeding severe enough (450-1500 mL) to require blood transfusion. The condition is often confused with other surgical emergencies such as appendicitis and ectopic pregnancy. An increased awareness of the problem in women of reproductive age and the use of laparoscopy, when indicated, will allow a more conservative approach to be adopted for those patients with minimal bleeding. The performance of an appendicectomy in the presence of blood in the peritoneal cavity did not appear to increase morbidity in those patients with a preoperative diagnosis of "appendicitis".
A case of acute appendicitis occurring in a 10- month-old infant is reported. The difficulties of an early preoperative diagnosis are highlighted. Perforation has usually occurred on presentation. However, prognosis may not necessarily be poor if active measures are instituted soon after perforation. The importance of active and aggressive preoperative resuscitation with fluids and electrolyte and intravenous antibiotics is stressed.
The use of an autologous ipsilateral internal iliac artery to restore circulation after excision of a ruptured femoral aneurysm in a patient addicted to drugs is described. Autogenous vein graft was not available. The advantages of using the internal iliac artery in this situation are discussed. The use of internal iliac artery graft in this situation has not been previously described in the literature.
One hundred children with peritonitis resulting from a perforated appendix were treated with ceftazidime or netilmicin. Metronidazole was added to both groups to treat the anaerobic organisms commonly associated with the infecting aerobic organisms in peritonitis. Escherichia coli was the most common aerobe found in peritoneal pus. Wound infection occurred in nine patients of the netilmicin group and in none treated with ceftazidime (P less than 0.01). No bacterial resistance was evident in the ceftazidime group, but gram-positive streptococci found in eight patients were resistant to netilmicin. Thus it is recommended that an antibiotic of the penicillin group be added if netilmicin is used to treat peritonitis. The results indicate that ceftazidime was more effective than netilmicin in the treatment of children with peritonitis resulting from a perforated appendix.
A 1 year review of 529 cases of acute appendicitis, treated at the University Hospital in 1990, was performed. Perforation rate was 23.7% and delay in diagnosis was found to be significant. Patients above 50 years of age were particularly at risk. Diagnostic error was 19.3% and it was a problem not only in young women but also in children. Temperature and rectal examinations were not found to be helpful in the diagnosis in contrast to leukocytosis. Waiting time for operation was long (median 7 hours), be it for a perforated or a nonperforated appendicitis.
A rare case of spontaneous rupture of a branch of the uterine vein in a primigravida is discussed. The patient with an uncomplicated pregnancy presented with signs and symptoms suggestive of abruptio placenta with foetal distress. Lower segment Caesarean section was performed. The cause of acute pain was identified to be intra-abdominal bleeding secondary to the rupture of a branch of the uterine vein. The pathophysiology of the problem is discussed.
Five cases of renal angiomyolipoma which underwent spontaneous rupture are described. These patients presented as an "acute abdomen" for which the diagnosis was not initially apparent. A high index of suspicion is required to make the diagnosis even with modern imaging techniques. The treatment of these tumours is discussed.
Ruptured splenic artery aneurysm during pregnancy is a rare event with high maternal and fetal mortality rate. A case of ruptured splenic artery aneurysm in the post partum period is presented. The literature is reviewed on pathophysiology, clinical presentation and management of this rare and potentially fatal entity.
We present a rare indirect nontraumatic cerebrospinal fluid (CSF) fistula secondary to a fourth ventricle ependymoma. The fistula resulted from rupture of the left temporal horn, distant from the tumour. The fistula was well demonstrated by MRI. High-resolution CT demonstrated a defect in the roof of the sphenoid sinus, but no leakage of CSF was seen on CT cisternography.
A case of spontaneous rupture of uterine artery in the second trimester of pregnancy is described. Haemorrhage from rupture of uterine artery during pregnancy was discovered at laparotomy. This was an unusual but serious complication of pregnancy. This condition is extremely rare and one must consider it in cases of incomprehensible abdominal pain with or without haemodynamic collapse. A review of the literature revealed only four similar cases so far. This pregnancy continued till 37 weeks pregnancy and had a spontaneous vaginal delivery. Immediate institution of effective resuscitative measures and early surgical intervention were essential to both foetal and maternal survival.
An inguinal hernia that suddenly becomes irreducible may be secondary to a variety of other underlying conditions which can occasionally mislead the attending surgeon. Benign, inflammatory or neoplastic processes, as well as surgical emergencies such as intraperitoneal or retroperitoneal haemorrhage, have all been previously reported to mimic an inguinal hernia that suddenly becomes irreducible with or without clinical features of strangulation. We add an additional interesting presentation to this list in the form of a ruptured ectopic pregnancy, which is the first such case reported in the literature. A swelling in the groin may be much more complicated than it seems on superficial consideration and good clinical acumen is constantly required in managing such cases if a satisfactory outcome without any morbidity is to be expected.
A young man with HIV presented with biliary peritonitis secondary to spontaneous common bile duct perforation. Investigation revealed that the perforation was due to Mycobacterium tuberculosis. Tuberculosis of the bile duct is uncommon and usually presents with obstructive jaundice due to stricture. Bile duct perforation due to tuberculosis is extremely rare. Its management is discussed.
We report a case of delayed diagnosis of tarsal tunnel syndrome caused by a ganglion arising from the talo-calcaneal joint. Unusually the symptoms were mainly due to the lateral planter nerve compression with a positive Tinel's sign. A surgical decompression was successful in relieving the dysaesthesia in spite of a 7 years history.
Pre-natal diagnosis of intra-abdominal pregnancy is difficult. Ultrasound has been the frontline modality to date; however, it gives a diagnostic error of 50-90% and its use is disappointing. In recent years, MRI has emerged as an appealing imaging modality. With its good soft tissue contrast and non-ionizing property, it acts as a means of definitive non-invasive assessment before surgical intervention when ultrasound is inconclusive.