Jaspreet Singh

Rectal perforation by impacted fecaloma—a new mechanism proposed

Editor: A fecaloma is a mass of accumulated feces that is much harder in consistency than a fecal impaction. The rectosigmoid area is the common site for fecalomas [1]. Fecal impaction, defined as a “compacted, immovable mass of feces filling the rectum,” is commonly seen in chronic constipated patients. It can result in obstipation, the inability to pass stool or gas, but can also present with diarrhea, because liquid stool can pass around the impaction. If untreated, fecal impaction may result in a variety of complications, including stercoral perforation [2]. We describe a patient with stercoral perforation with an atypical location. A 65-year-old female presented with nonpassage of flatus and stool for 8 days, abdominal distention for 5 days, vomiting and fever for 1 day, and a history of constipation for the last 5 years. On examination the pulse rate was 104/min and BP, 104/76 mmHg. The abdomen was distended, and generalized guarding was present. Per rectal examination revealed hard fecoliths. Plain X-ray of the abdomen (Fig. 1) showed radiopaque masses all over the colonic area. Ultrasonography of the abdomen showed content-filled gut loops with free fluid. Contrast-enhanced computed tomography of the abdomen revealed free air and fluid in the peritoneal cavity with prominent small and large bowel, suggestive of bowel perforation. The patient was explored urgently. On exploration about 1 L of foul-smelling blackish fluid was aspirated from the peritoneal cavity. A large gangrenous patch of size 5 cm × 5 cm was present in the upper rectum on the posterior wall with a stony hard fecolith protruding through the necrosed central part (Fig. 2). The entire colon was loaded with hard fecoliths which were extracted (Fig. 3). A segment of gangrenous rectosigmoid was resected, the rectal stump closed, and the distal cut end of the sigmoid colon brought out as an end colostomy. Fecal impaction causes the intraluminal pressure within the colon to increase and exceed the capillary perfusion pressure in the bowel wall, resulting in pressure necrosis of the wall and eventually ulceration and perforation. The most common sites of fecal impaction are the sigmoid and rectosigmoid colon, because here much of the water has already been reabsorbed from the feces, which can then develop into hardened masses or scybala [2]. In addition, the distal colon, particularly along the antimesenteric border, has a relatively poor blood supply, making it more susceptible to pressure necrosis from scybala. Finally, because these areas of the colon have the narrowest diameter, they allow the formation of higher intraluminal pressure in the event of fecal impaction which can lead to perforation [2]. Mauer et al. proposed four diagnostic criteria of stercoral perforation [3].

Hepatopulmonary hydatid disease

A 31/2-year-old girl presented with multiple large hydatid cysts, one in each lung and one in the right lobe of the liver. These were managed successfully at three separate surgical operations. A literature review suggests that patients of this age rarely have multiple hydatid cysts of such large dimensions in different organs.

A rare case of delayed presentation of congenital diaphragmatic hernia with gastric volvulus

A Bochdalek hernia is a posterior congenital defect of the diaphragm, usually on the left hemidiaphragm, caused by a lack of closure of the pleuroperitoneal canal between the eighth and tenth week of fetal life during the embryonic development. It typically presents in the neonatal period with severe respiratory failure. Here we present a 28 year old man with history of episodes of severe dyspnea, pain in epigastric region who arrived to the emergency room, having tachypnoea with oxygen saturation 80% on room air. During his medical work-up we incidentally found gastric volvulus with diaphragmatic hernia. It was managed with reduction of the herniated and rotated stomach and spleen back to the peritoneal cavity and closed the defect by open approach. This type of hernia is uncommon in adults. In this age group, there are two different clinical presentations: asymptomatic patients who are diagnosed incidentally when abdominal organs are found in the thorax in a chest X-ray, and symptomatic patients due to side effects of incarceration, strangulation, hemorrhage and visceral perforation in the chest cavity.

Adult right-sided Bochdalec hernia containing perforated colon

IntroductionThe literature describes less than a dozen cases of right-sided diaphragmatic hernias. Herein, we present an unusual case of this kind in an adult patient. The hernial contents included the liver, omentum and large bowel.AimThis case is reported for its rarity because it was identified in an elderly patient on the right side of the diaphragm with the liver being among the contents of the hernia. The present case is unique as a right-sided Bochdalek hernia containing perforated colon is a rare finding.Case profileA 40-year-old male presented to the emergency room with distension of the abdomen and pain of 4 days duration. He was found to be tachycardic and normotensive. The right hemithorax showed decreased expansion as compared to the left and breath sounds were diminished on the right side. A chest X-ray revealed bowel loops in the right hemithorax and air-fluid level in the abdomen suggestive of small bowel obstruction. Computed tomography identified herniation of the right colon and liver through a posterior defect in the right hemidiaphragm. After adequate resuscitation, a laparotomy with a right sided thoracotomy was performed, and the hernia was explored. The patient had an eventful recovery in terms of wound infection. No signs of recurrence were observed during 12 months of follow-up.ConclusionAdulthood right-sided Bochdalek hernias are extremely rare. Signs and symptoms can be non-specific and the present case highlights the importance of acquiring a CT scan at the earliest opportunity. This is crucial to the management of these patients as a delay in diagnosis can increase the risk of mortality.

Transmural migration of surgical sponge into the stomach with outlet obstruction: Rare Case

AimTo highlight the unusual postoperative clinical presentation of a retained sponge.BackgroundRecognition of postoperatively retained foreign bodies is essential but often delayed, either because of medicolegal implications or because of a confusing clinical presentation and non-specific imaging features. In contrast to radio-opaque materials which are detected at follow-up imaging, radiolucent objects like sponges create problems in identification.Case ReportA 30-year-old lady presented with intermittent non-bilious vomiting, epigastric pain and fever. Contrast-enhanced computed tomography of the abdomen showed a heterogeneous mass in the duodenum with multiple air pockets. Surgical exploration revealed a full-size surgical sponge with one end embedded in the gallbladder fossa and the other perforating the antrum of the stomach, thus causing an obstruction. The sponge was retrieved, and distal gastrectomy with Billroth II anastomosis was performed. The postoperative course was uneventful.ConclusionA high degree of suspicion and awareness of non-specific symptomatology associated with retained sponges after surgery is essential for early diagnosis and correct treatment.