Monday, January 14, 2008

Peritonitis

Two similar cases recently, with different outcomes. A 60 year old lady apparently was in a minor car accident the previous week, but didn't seek medical treatment. She had horrible back pain and, according to family members, she self medicated by popping aspirin and motrin. She develops abdominal pain. Three days later, her husband brings her into the ER because "she isn't acting right". She takes two steps into the triage area,stumbles, babbles incoherently, and basically arrests on the floor. The nurses note that her toes and fingers are blue as the code starts. Evetually she is resuscitated and intubated and vitals return. They run her through the CT scan and an enormous amount of free air is seen. At this point her labs trickle back. Extreme metabolic acidosis. Potassium 7.2. BP 80/30 on three pressors. This is point where Buckeye Surgeon is called. The nephrologist is already there when I arrive (at 2AM! nice work!)frantically trying to get the potassium corrected with bicarb, insulin, etc. The woman is mottled blue in all her extremities. Her eyes are fixed and dilated. She basically looks like a corpse hooked up to machines. I tell the daughter, who's a wreck, that the prognosis is extremely grim. She wants everything done, though. I get a quick head CT to make sure there's no obvious infarct or impending uncal herniation. It's normal, so I book the case at 4am. The anesthesiologist is just furious. What do you hope to accomplish, she hisses at me. We'll see, I say. I end up putting in all the lines and then we get started. Whoosh of air as the peritoneal cavity is entered and then a tidal wave of liquid green succus. Ten minutes are spent evacuating the contamination. I have an idea what the problem is going in, so I target the foregut. Sure enough, there's large anterior perforated duodenal ulcer. And this baby has been like this for days. Strands of fibrinous exudate span the peritoneal cavity like melted mozzarella. Chunks of corn and other vegetation float by in the irrigation fluid. The omentum, unfortunately, is a shriveled, near necrotic, mess. Usually for perforated duodenal ulcers, the move is to do a Graham Patch with a tongue of omentum to seal the hole. That wasn't possible in this case. the omentum was like used tissue paper. So I used a little trick a guy at Cook County Hospital taught me. I liberated the falciform ligament and boom, I had a nice strip of well vascularized adipose tissue to cover the hole. Graham patch in the standard fashion. Hole closed. We irrigated with ten liters of saline, closed, shipped her to the ICU, and crossed our fingers. We dialyzed her that night and were able to slowly wean the pressors. Amazingly, by ten the next morning, she was off pressors completely and was opening her eyes and following commands. Nice save, I'm thinking. But then around 4pm she starts throwing some PVC's and then suddenly drops her pressure. Troponin comes back over twenty. She goes into Vfib, codes, and dies. Basically she died from a massive post-op MI/ventricular arrythmia. Sometimes you can do everything right, but the patient's ticket is already stamped. Sucks to come that close though, to bring someone back from the dead, only to ultimately lose them. You wonder what the hell took her so long to come into the hospital. She'd been curled up in bed for days, apparently. Well, we gave it a shot. Definitely not wasted resources. Anyone with an acute abdomen (peritonitis, free air) deserves at least a shot in the OR, if that's what family/patient want. You just aren't going to win all those battles.

The other lady was about the same age, with a similar co-morbidity history(CAD, COPD,DM). She came in with vague lower abdominal pain and was admitted to the floor after an intial negative work-up. The pain worsened over the next several hours and she started dropping her pressures and became anuric. They called me while I was at the movies. Stat repeat CT scan was done which showed diffuse free air. When I arrived in the ICU, she was pale and deathly. Her pressure was 64/40 and she had obvious peritonitis. I resuscitated her with saline, pressors, etc. and booked her for OR. Now I've done a lot of operations for free air/perfed bowel and it's always satisfying to get that whoosh of air as you slice open the peritoneum. But this case was a little different. This was no little whoosh. This was more like Mount St. Helens blowing its top. It was like a poop grenade had gone off in our faces. Good times! Especially at 1 in the morning on a Friday. The assistant and I scrubbed out, re-gowned and got to work. After scooping and sucking out about 3 gallons of stool we could finally see. The pathology was a perforated cancer in the rectosigmoid area, the hole the size of a golf ball. I resected the left colon and gave her a colostomy. Again, we irrigated with ten liters of fluid. At the end of the case she was on levophed and vasopressin and nothing was coming out of the foley. Back in the ICU, I slammed her with fluids all night. By daybreak, her BP was holding steady, vasopressors were off, and there was a faint trickle of urine output. Within 24 hours she was extubated and was making copious urine. The stoma is working and she's bugging me about when she can eat. Now that's the way it's supposed to work out.....

6 comments:

sterileeye said...

Always fascinating to read your case reports.

It strikes me how many details doctors tend to remember about old cases.

Even dictating a detailed journal entry after 5 hours of surgery seems hard to me.

But then again, success or failure, it's all in the details. So that's maybe why they stick?

rlbates said...

"And that's the way it's suppose to work out" Don't we wish it would--every time.

cutonthedottedline said...

Had the second lady had an earlier CT, and did it show anything? Nowadays it's hard to get through the ER, let alone admitted for belly pain, without having a CT done.

So what do you do when you get called away from a movie? Do you ever go back to see the whole thing, or just give up on that one?

Buckeye Surgeon said...

Alice- The initial CT was read as diverticulosis without diverticulitis. In retrospect, it sure looked like diverticulitis to me. She was in the hospital three days until decompensation.

The movie left was called Juno. I liked the twenty minutes or so that I saw. My wife loved it. She's got decent taste, so I'd take her word for it. I'll try and catch it when it comes out on DVD.

Sid Schwab said...

I had a case like one of those. I also watched a partner open a belly full of "air" using cautery, causing a blue flame like a torch; or like the old frat-party trick.

And thanks for stopping by with your "encouraging" words.

Kacey said...

How do you keep your lunch from winding up in your mask? I was a scrub nurse for C-Sections and worried about a runny nose from allergies, but your Mt. St. Feces eruption would have been a bit much.