By Tedler D. Depaynos, MD
It was late afternoon when the 86 year old female patient was brought to the Emergency Room due to severe abdominal pain. Actually she experienced similar episodes in the past but this was the severest of them all. She just laid down straight and not moving but kept on holding her abdomen and whispering “painful” in the dialect. A simple abdominal x-ray revealed “pneumo – peritoneum” or air in the abdominal cavity. It simply means that there is a perforation in the gastro-intestinal organ where the air came from.
A CT scan was done hoping that the site of perforation can be localized and consequently aid the surgeon but nothing definite was seen.
The patient gave a history of passing out “dinuguan” like stools and vomited fresh blood recently so that an upper Gastro-Intestinal or GI bleeding was entertained. Actually she had similar episodes in the past so that a gastro-endoscopy was done 2 years ago which revealed gastritis or inflammation of the stomach lining but no ulcer. Nevertheless, a perforated ulcer of the stomach or duodenum was entertained. The surgeons were hoping that it was in the duodenum because ulcer in the stomach especially at her age group has a high probability that it is due to gastric cancer.
What was puzzling to the surgeons pre-operatively was that the rigidity was more on the left lower quadrant of the abdomen which by x-ray and CT scan was filled with fecal material. A possible partial obstruction at the sigmoid area was considered causing the accumulation of the fecal material in that area as seen through the diagnostic procedures. One of the young Surgical Residents voiced out that it could be the site of perforation. Agreeing that the rigidity on that area was due to the accumulated leakage from the perforation causing infection or peritonitis, the patient underwent emergency surgery.
The patient initially was turning her head left and right refusing to undergo surgery and have her abdomen opened. She later consented when her children convinced her for how could she travel abroad when she was sick. One of her daughters recently arrived from where she was working overseas and they planned to bring her outside the country on a tour.
Upon opening the abdomen, plenty fecal material was seen and there was a large perforation at the distal colon or sigmoid validating the opinion of the young surgical trainee. The accumulation of the fecal material was seen by x-ray and CT scan but whether it was outside the intestine was not appreciated. More than an hour of peritoneal or abdominal washing was done and obviously the perforation occurred several days earlier. The daughter in retrospect could recall that the patient has been complaining of abdominal pain since two weeks ago but refused to be brought to the hospital. This is actually the usual attitude of elderly patients. They will just give consent to be brought to the hospital if the pain they are experiencing is no longer tolerable.
On closer examination, the site of perforation was an out pouching of the colonic wall in that area called diverticulum. It could be congenital in origin but with age and “wear and tear”, weakness of the wall of the diverticulum occurred causing it to eventually rupture and perforate.
The patient tolerated well the surgery and since the perforation cannot be closed primarily due to edema and infection a colostomy was done. What the surgeons were afraid most was the possibility of sepsis occurring because the bacteria and their toxins may enter the blood stream and could be distributed to the whole body system of the patient. This is actually one of the dangerous complications surgeons wanted to avoid so that they do emergency surgery even at unholy hours.
The post-operative period of the 86 year old patient was not smooth as expected and made the attending MDs constantly at her bedside. With lots of prayers, the patient was finally discharged with all smiles because she will be going on a European tour later courtesy of her children. She even agreed that her colostomy would be removed after her tour.**
