Peritonitis and sigmoid colon injury
One of the reasons why surgery appeals to me is the clinical input that makes a difference in the treatment of patients. Often in surgical patients, one decides whether to operate or not based on the clinical signs that the patient has. No test, X-ray or blood test, can make you change your mind once there are some key clinical signs present.
“Clinical” means the features that are found on questioning the history of the illness and found on direct examination of the patient at the bedside, without input from investigations/tests.
One such patient came at 11 o’clock one evening with abdominal pain. He had had a car accident four days prior to coming. He complained of abdominal pain but scans done at another centre (it’s always another centre ;-)) were normal. Abdominal examination revealed tenderness. There is pain in the abdomen when touched during examination. There was a sign called “guarding” present. That means that the abdominal muscles contract invountarily when the abdomen is pressed lightly. It is a sign that there is an irritant inside the abdominal cavity. This irritant is usually the presence of inflammation in the inner lining of the abdominal cavity (peritoneum), called “peritonitis”. There is also tenderness and guarding when there is pus, blood or other materials such as bile in the abdominal cavity. It’s an alarm signal for surgeons.
Some people come with abdominal pain and, on examination, these signs are found. I tell them they need an operation. What they want to know is how sure I am. They want to see some tests before they are convinced. This is important: when the surgeon has examined and decided that the signs are positive for appendicitis or some other cause of peritonitis, if all the tests are negative, surgery is still not avoidable. This is because no test can be as sensitive as the examining hand for peritonitis.
The patient who came with abdominal pain had peritonitis but he wasn’t convinced… until I took this X-ray:
Gas under the diaphragm. A sure sign of a leaking gas-filled organ (gastro-intestinal tract)
So off to surgery…
There was a tear in the sigmoid colon and faeces was pouring out from it. That was the worst kind of peritonitis, because faecal material contains a large amount of bacteria. This is life-threatening.
This was repaired. And the abdominial cavity washed out with lots of warm fluid.
So, the lesson for the day: trust your surgeon’s hands. Really.
To be a surgeon must be fascinating.
fascinating… i also trust ma surgeon’s hands
*wink*
Trust surgeon’s hand? Only if it is a competent and experienced one
I don’t know if I can honestly say I trust all surgeon but I trust you lah Dr Bernard! You seem to know what you are doing all the time. I am truly impressed.
You know, when I had my gallstone problem, after 4 months, I finally managed to get my appointment to see the surgeon whose assistant examined me first. I told him I was thalassemic and he asked me “What is that?”
Then 2 weeks before my surgery, the surgeon called me back and told me that they can’t operate on me because my haemoglobin was very low from a blood test taken 6 months ago. I had to pleas with them to operate on me because delaying the surgery is not going help my haemoglobin. In the end, my haemotologist had to call the surgeon to assure them I would be fine.
So, how can I trust all surgeons but I TRUST YOU!
Hmm, sounds like a ’shitty’ accident. Ha ha ha ha.. (Lame joke intended)
Capt Picard, nothing like a starfleet captain, sir!
Kat, you’d better!
just me, well.. it’s not a difficult assessment.. just needs good hands and enough guts. Whoever your surgeon is, if you’re seeing him or her… you have to place your trust there already.
Judy, well.. ohhh, you have thalassaemia. It isn’t that often that surgeons see thalassaemia patients. So, it’s excuseable for him to not know it. Hehe
If your Hb was very low, you must be having intermediate Thalassaemia. That might account for the dark colour of your stone (saw it on your blog before).
jonzz, loads of it.
Thank God I have not had any experience with any surgeon yet.
Knowing I have to see one will scare the guts out of me first, I think. I don’t mind delivering another baby to having to undergo an operation…yes, I am that scared!
Bernard, what is intermediate thallassaemia? Thanks for the explanation which is really helpful. I must tell my husband who wonders why the stone is black (he thinks it’s been in my gallbladder for a long, long time).
Thank God I have taken my dinner. Hope you can enlighten me. What is the difference between peritonitis and diverticulitis? I am a diverticulitis sufferer and the pain lasts for days with diarrhoea and flatulence. I trusted my physician and he did nothing, so I had to bear with it when the pain comes. How would you treat diverticulitis? Really appreciated it you could share your knowledge on this.
just me, really… having a baby is probably worse, actually.
Judy, i’m no haematologist, but there are various types of thalassaemia, depending on how many of the haemoglobin genes are abnormal. You sure don’t looks like one with MAJOR thalassaemia (they have a charateristic appearance because of the frequent transfusions). And you said that your Hb level was very low (minor thalassaemia patients usually have just mildly reduced Hb level). So i guess, it might be intermediate thalassaemia.
Anyway, the reason why it’s black is because the waste product of breakdown of haemoglobin is bilirubin pigment which gives bile its characteristic colour. Since thalassaemia causes more rapid turnover (breakdown and production of new red blood cells), there’s more bilirubin being produced than normal and the stones tend to be dark or black in colour.
AGM, colonic diverticuli are out-pouching of the inner lining of the colon. They are usually harmless but can become complicated by diverticulitis (i.e. the diverticuli become inflammed). Usually these are treated by a course of antibiotics.
Peritonitis, on the other hand, is a life-threatening condition as there is inflammation, usually infection, of the abdominal cavity. Patients can quickly become septic and can die if untreated.
Occasionally, the diverticuli might perforate (burst) and form localised abscesses around the colon or might spread all over the abdomen… i.e. peritonitis.
Thank you so much for taking your time to explain. What puzzled me is that I go to toilet regularly and I don’t suffer from constipation. I wonder why my diverticulitis pain and inflammation come with flatulence and diarrhoea, and usually occurs around the time of my menstruation period. Perhaps the diverticuli got blocked because of some roughage or fibres. The course of anti-biotic is to cure the inflammation only, right?
AGM, yes … antibiotics is for when there is diverticulitis.. when there’s inflammation.
Once a diverticulum (singular of diverticuli) has formed, it will remain permanently. Sometimes they do get stuffed with faeces (all the fibre has turned to faecal material by the time it reaches the large bowel), but that is usually harmless as well. Occasionally, however, bacterial overgrowth occurs in the diverticulum. Then that can cause bloating and diarrhoea.
Taking fibres is good as it produces bulky soft stools that are easily evacuated on a regular basis… helps to reduce incidences of bacterial overgrowth.
About the symptoms (you should consult your doctor about this): sometimes the diverticuli might not be the cause of the symptoms. Other causes, such as irritable bowel syndrome (IBS) might cause symptoms and the diverticuli are just innocent bystanders. Consult your doctor about this.
Thank you Dr. Bernard. Wish I could see you for a consultation.
As usual, very informative. Thanks for sharing!