Abdominal pain after a surgery

Chief Complaint A 76 y/o male is presented with abdominal pain with nausea and vomiting. History 6 days prior he had surgery for right femur fracture with proximal intramedullary nail. He has h/o surgery for appendectomy. Vitals *Blood pressure-125/75 mmhg, HR- 109 beats/min, Respiratory rate-19 bpm, Temp-99.3 degree F. Examination Abdominal distension on rt side. Other examination is unremarkable. Investigations Hb- 12.1 g/dL, WBC-13.05 × 109/l, C-reactive protein 18 mg/dL. CT- thickeness of small bowel with free air noted on rt side + perforation of jejunum. Treatment Please give your advice.

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Acute peritonitis as per usg report jejunal perforation and free air in peritoneum Leucocytosis H/o femoral nailing Post surgical sepsis with intestinal perforation which could be bcz of NSAIDs RT to put in stomach for aspiration Broadspectrum antibiotics in iv drip Inj Ceftriaxozone and inj meteronidazole Inj dexamethasone Inj pantaprazole inj ondestron Once infection is controlled Surgical intervention for end to end anastomosis of perforated jejunum Maintain electrolyte balance and vitals

Thanx dr Dinesh Gupta
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It is a case acute surgical emergency. Acute Peritonitis due to perforation of jejunum . Preparation before surgery is indicated 1.NPO 2.RT - suction 3.IV fluids and correction of dehydration and electrolytes 4.Parenteral antibiotics- 3rd generation cephalosporins and metrogyl infusion 5.All investigations for G.A Surgery - Exploratory laparotomy with suction of peritoneal fluid, closure of jejunal perforation in 2 layers by 2- zero vicryl and thorough Peritoneal toilet before closure after insertion of 3 intraperitoneal drains

Free air in abdomen with perforation of jejunum, is indicative of perforative peritonitis It is accompanied by tachycardia, raised WBC count and raised CRP It needs surgery of emergency exploratory laparotomy to drain the perforation and to do surgical repair

IT'S A..CASE OF.. MEDICAL EMERGENCY.. JEJUNAL.. PERFORATION..LEADING TO.. PERITONITIS .. NEED'S.. IMMEDIATE SURGICAL INTERVENTION.. LAPAROTOMY..

Tnx Dr Shivraj Agarwal sir
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Can it be a case of.. Mesenteric artery thromboembolism... as a sequel to fracture femur/fat embolism....... leading to ischenic entercolitis?

Surgical contraindications: Pts non agreement for sx and pts agreement for medical mx, no evidence of signs of peritonitis, Cect abdomen- revealing a sealed off perforation, contraindications for Anaesthesia and surgery - Respiratory, Cardiovascular comorbidities - CHF, RESPIRATORY FAILURE ETC-- Get a Cect abdomen done - if sealed off and pt develops no signs of peritonitis - consider medical Mx Laparoscopic/Emergency laparotomy + primary closure of perforation/Resection and anastomosis based on the size of perforation. Good post OP care as the pt is a geriatric with h/o recent previous Sx. Proper counseling, risk explanation and the need for surgery to be explained to the pt and attenders before taking further step.

SUGGESTIVE. OF .PERFORATION Of JEJUNUM NEEDS EMERGENCY ..SURGICAL. .INTERVENTION