Unusual Case of Peritonitis
A 23-year-old male presents to the ED with several days of abdominal pain. He is otherwise healthy and denies any other symptoms.
On exam, he has diffuse peritonitis, but no other obvious findings. He is tachycardic with a heart rate in the 110s-120s. His blood pressure is 100s/60s. No significant medical or surgical history. No remarkable events recently.
He had plain films of his chest and abdomen.
Plain film of the chest and upper abdomen
What's going on?
Differential diagnosis?
Perforated hollow viscus- gastric or duodenal ulcer, bowel obstruction leading to perforation, procedural complication (EGD, ERCP).
On further questioning, the patient endorses a recent soccer game during which he blocked a goal and was hit in the stomach. Unsure if it was the soccer ball or a kick to the stomach.
He then had a CT of his abdomen and pelvis.
CT of the abdomen and pelvis, representative slices
What's going on?
Diagnosis? Intervention?
Free air (pneumoperitoneum) and free fluid are consistent with a perforated hollow viscus. No clear source on the CT. This requires abdominal exploration.
We proceeded with exploratory laparotomy. Found liters of succus. There was a single perforation of the small bowel that was resected and anastomosis was performed. The abdomen was closed and a drain was placed.
Intraoperative Findings
Management of Peritonitis from Perforated Hollow Viscus
     The hollow viscus refers to the gastrointestinal tract from the esophagus to the rectum. Pain associated with hollow viscus perforation is classically acute onset, constant, severe, and worse with movement. The peritoneal lining of the abdomen becomes inflamed in reaction to the leaking enteric contents. This is a surgical emergency.
     The diagnosis can be made with the visualization of pneumoperitoneum on an upright chest x-ray (lucency under the diaphragm). A patient with peritonitis and free air requires surgical exploration. A CT scan can help identify the underlying pathology, but is not mandatory and should not delay operative intervention. Non-operative management is reserved for the patient with a sealed perforation (example- retroperitoneal duodenum) or a patient who is a prohibitively high-risk operative candidate (example- patient on palliative or hospice care).
Cultural differences
     Not all cultures have adopted the practice of Western medicine. In some cultures, people still seek advice and medical care from traditional healers. Unfortunately, this can delay treatment if a patient requires operative intervention. Some of the treatments provided by traditional healers can also lead to further injury.
     This patient with a small bowel injury was seen by a traditional healer several times before he was finally brought to the hospital. The marks on his skin are the result of a practice of cutting the skin to heal the cause of his abdominal pain.
     Another patient was brought to the hospital for a severe infection of his genitalia. By the time he came to the hospital, his infection was so extensive that he required a debridement of a large portion of the skin in his perineum. He had been seeing a healer who was treating him with a topical solution that had essentially burned his skin, so in addition to the underlying infection, he had severe tissue damage.