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|Year : 1990 | Volume
| Issue : 3 | Page : 169-70
Duodenal obstruction due to appendicular abscess (a case report).
The obstruction to the third part of duodenum due to appendicular abscess is reported here. The abscess had tracked behind the mesocolon and obstructed the duodenum. The case was treated by drainage of abscess and anterior gastrojejunostomy.
|How to cite this article:|
Hardikar J V. Duodenal obstruction due to appendicular abscess (a case report). J Postgrad Med 1990;36:169
The mortality and morbidity following perforated appendix is unacceptably high. Postoperative complications like intra-abdominal abscesses, septicemia are well known. In the present case, I wish to report the case of intraabdominal abscess causing obstruction to the third part of duodenum.
Mr. D, 25-year-old man previously in good health presented with abdominal pain and fever of 8 days duration. On admission, he was very toxic. The pulse rate was 130/min. and B.P. of 100 mm of Hg. Abdominal examination revealed generalised tenderness, guarding and rigidity. Peristaltic sounds were absent. A clinical diagnosis of perforative peritonitis was made. His investigations were as follows: Hb-9.5 gm %, WBC-14800/cmm, serum Na-130 mEq% and serum K-3.6 mEq%.
Plain X-ray abdomen did not show any characteristic findings except for generalised around glass appearance and few dilated loops of bowel. After initial resuscitation with ringer lactate solution and administration of gentamicin, ampicillin and metronidazol, the patient was explored.
The operative findings were as follows: Peritoneal cavity contained 300 ml of thin purulent fluid-Terminal ileum, caecum and omentuni had formed a mass in right iliac fossa. After separating these adhesions gently, the abscess cavity was found behind the terminal ileal mesentry. The distal portion of appendix was sloughed out and lying free in abscess cavity.
The remaining proximal portion of appendix was removed and the stump was buried in caecal wall. A drain was inserted into abscess cavity. After peritoncal lavage, the abdomen was closed. Early post-operative period was uneventful. After 5th post-operative day when patient was already oil liquid diet, lie started vomiting. At this stage, the oral intake was witliheld. The nasogastric tube was re-inserted and intravenous fluids given. Nasogastric aspirate remained high for nearly 72 hours. A thin barium was ordered to rule out mechanical obstruction which showed obstruction to third pait ot duodenum (see [Figure - 1]). The patient was reexplored. The findings were as follows: 1. Caecum, terinitial ileum and the site of buried appendicular stump were normal. 2. Previous abscess cavity was already contracted. 3. There was an abscess located bellind gastrocolic ligament in front of 3rd part of duodenum. When the abscess was drained after opening the gastrocolic ligament, the cavity was found to be connecting with, the previous abscess through a very small opening. A drain was inserted to abscess cavity and anterior gastrojejunostomy was carried out, Subsequently paticiii made a smooth recovery.
The incidence of Post-operative complications following appendicectomy is under 5% provided the operation is performed before perforation of appendix. The mortality rate of generalised peritonitis following perforated appendix is still over 5%. Intra-abdominal abscesses do occur following perforated appendix. They occur within 7-14 days after the onset of infection. They are often located in pelvis. They can extend to right subplirenic space, lift paracolic gutter and so on. The clinical manifestations include persistent fever, localised tenderness, a dynamic ilcus, displacement of viscera etc. The downward displacement of fundus and widening the space between fundus and diaphragm has been reported.
In present case third part of duodenum was obstructed due to extension of appendicular abscess. This was treated by drainage of abscess and gastrojejunostomy. Since this is a rare complication of intraabdominal abscess, I wish to report this case.
I wish to thank the Dean, Seth GS Medical College and King Edward Memorial Hospital for allowing me to publish this report.
Hardy JD. In: "Complications in Surgery and their Management." Philadelphia, London, Toronto and Sydney: WB Saunders Company; 1981, pp 610-614.