Case History

A 22 year old female presented with complaints of abdominal pain, abdominal distension, nausea, vomiting and anorexia. On examination the abdomen was distended with diffuse tenderness. But there was no guarding, rigidity or rebound tenderness.

Abdomino-pelvic CT scan was suggestive of Intestinal obstruction and Abdominal Tuberculosis. It revealed  distended bowel loops, large amounts of ascites, symmetrical thickening of the peritoneum and mesentery, nodular thickening of greater omentum and mesenteric lymphadenopathy.

After conservative management for first 24 hours, patient showed no signs of improvement. An exploratory laparotomy was planned. Intraoperatively it was found that Multiple Adhesions between bowel loops and an omental band were causing the obstruction. Adhesiolysis was done and thorough wash was given. Omentum, peritoneum, bowel wall, uterus and adnexa were all seen studded with tubercles. Omentum was thickened and nodular, a piece of it was taken and sent for HPE. Ascitic fluid was blood stained and a sample was taken for biochemical analysis.

Postoperatively patient's condition improved and she passed flatus on 3rd POD and passed stools on 5th POD.  Patient was started on antitubercular drugs and was discharged on 8th POD.

Tuberculous peritonitis: Important Points to remember 

Peritoneal tuberculosis is the sixth most common site of extrapulmonary tuberculosis. The top five are lymphatic, genitourinary, bone and joint, miliary, and meningeal. 

Only 17% of cases of peritoneal tuberculosis are associated with active pulmonary disease.  

Abdominal swelling caused by ascites formation is the most common symptom, occurring in more than 80% of cases. 

A positive tuberculin skin test response is present in most cases. But only approximately 50% of these patients will have an abnormal chest radiograph.

Abdominal imaging with ultrasound or CT may suggest the diagnosis but lacks the sensitivity and specificity to be diagnostic.

Ascitic fluid adenosine deaminase activity, in particular, appears to be highly sensitive and specific for tuberculous peritonitis.

The ascitic fluid SAAG is less than 1.1 g/dL, indicating high protein concentration in the ascitic fluid

Microscopic examination of ascitic fluid for acid-fast bacilli identifies the organism in less than 3% of cases, and culture results are positive in less than 20% of cases.

Reference

Sabiston Textbook of Surgery 20th Edition

3/29/2018 07:19:00 PM

Adhesive Band causing Intestinal Obstrucction

Which protein is responsible for formation of adhesions?

Adhesions are formed by fibrin deposits onto the damaged tissues. The fibrin acts like a glue to seal the injury and builds the fledgling adhesion. In body cavities such as the peritoneal, pericardial and synovial cavities, a family of fibrinolytic enzymes may act to limit the extent of the initial fibrinous adhesion, and may even dissolve it. In many cases however the production or activity of these enzymes are compromised because of injury, and the fibrinous adhesion persists. If this is allowed to happen, tissue repair cells such as macrophages, fibroblasts and blood vessel cells, penetrate into the fibrinous adhesion, and lay down collagen and other matrix substances to form a permanent fibrous adhesion.

What are the types of adhesions?

There are three general types of adhesions: filmy, vascular, and cohesive

What percentage of individuals develop adhesions after surgery?

A study showed that more than 90% of patients develop adhesions following open abdominal surgery and 55–100% of women develop adhesions following pelvic surgery [1].

Does adhesive intestinal obstruction always require surgery?

Simple obstruction secondary to an adhesion is most likely to resolve nonoperatively.

What is the most common cause of small bowel obstruction?

Adhesive obstruction is the most common cause of small bowel obstruction. In the United States, peritoneal adhesions account for over half of the cases of small bowel obstruction.


View the link below for more important points:
http://www.worldsurgeryforum.net/2015/05/small-bowel-obstruction-due-to.html

References

[1] Liakakos, T; Thomakos, N; Fine, PM; Dervenis, C; Young, RL (2001). "Peritoneal adhesions: etiology, pathophysiology, and clinical significance. Recent advances in prevention and management". Digestive surgery 18 (4): 260–73. doi:10.1159/000050149. PMID 11528133

6/21/2016 11:54:00 PM