Severe ‘Gastritis’? - Case report, KCH, 2011.

Management of penetrating injury to the left upper abdominal wall. Diaphragm.

1. Severe ‘Gastritis’?
-Case Report and Literature Review
Dr Ehsan Weidi
Miss Katie Adams
Mr Raimundas Lunevicius
Mr Andrew Leather

2. Case Presentation

3. A&E Referral
22 year old man in Resus
Previously fit and well
Severe haematemesis
Tachycardic, hypotensive, hypovolaemic
For surgical review ‘just to be aware’ prior to ITU
admission for optimisation then possible OGD

4. Presentation
June 2012:
1/7 Generalised abdominal pain, D&V
Pain improved with Buscopan
Diagnosed Gastritis Home with advice
Attended A&E 3 days later (index admission)
4/7 worsening abdominal pain and distension
Vomiting +++ dark brown fluid ?haematemesis
Dark PR blood x5

5. Background
Occasional alcohol
Regular cannabis smoker
Admitted April 2010
Stabbing x2
Right upper quadrant
Left thoraco-abdominal region
Conservative management
Following this two admissions in 2010 and 2011 with
?gastritis. Received Helicobacter Pylori eradication

6. Initial assessment
Pale and Clammy: RR 20, 90% o/a, BP 116/96, HR 154, Temp 36
-Triaged to Resus where he deteriorated BP 78/38
Difficult historian due to tachpnoea & pain
LUQ tenderness
Distended
Lower abdominal peritonism??
?Decreased AE Left base

7. Results
ECG
Sinus Tachycardia
VBG
Lact8.1
pH 7.?
pO2 ?
pCO2?
Bloods
Hb 17.4
WCC 7.37
Na 126
Urea 25.5
Cr 240
Bil 21
CRP 574.0

8. Differential Diagnosis?

9. Radiology: chest x-ray

10. Radiology: chest x-ray

11. Previous admission April 2010
Brought in by police who found Pt sleeping in a park
with multiple stab wounds following a confrontation
with a man and his dog the night before.
Injuries
1cm wound Lower Right costal margin in the anterior axillary
line
2cm wound left mid axillaryline 9
th
intercostalspace
X4 small lacerations to left forearm (canine)
Abdomen Soft
Chest clear with equal air entry bilaterally

12. Initial CT

13. Previous admission April 2010
Insert initial CT coronal here for F1/2’s to look at
Any thoughts

14. Previous admission April 2010
CT scans
Liver and Kidney Lacerations
Segment 6 Liver Laceration
Right upper pole renal laceration
Small amount of free fluid in the paracolic gutter
No evidence of bowel injury
Conservative management
Patient lost to follow up post-discharge

15. Follow Up CT

16. Differential Diagnosis?
Unrelated to previous injury:
Peptic Ulcer Disease with bleeding ulcer
Perforated Peptic Ulcer
Related to previous injury
Herniationof abdominal hollow viscusinto left
hemi-thorax:
Stomach? /Small Bowel? /Large Bowel?
With/without incarceration/perforation
With/without pseudoaneurysm
Mediastinitis

17. Initial Management
Rescusitation
Arterial Blood Gas
Cathater
Analgesia
URGENT CT arranged –any specific requests?

18. Radiology: CT-scan

21. Initial CT

22. Follow Up CT

23. Follow Up CT

24. Management
MCCU for pre-operative optimisation
Urgent Laparotomy
Findings:
Incarceration of transverse colon and greater omentum
within left thoracic cavity through 5-7 cm diaphragmatic
defect (dome of the L hemi-diaphragm)
Grossly dilated proximal large bowel & Small bowel
Transition point–point of dital transverse RE-ENTERING
abdominal cavity from thorax
No perforation.
Haemo-serous fluid in left chest.
Necrotic gangrenous transverse, right colon and omentum

25. Management
Procedure
Defect enlarged on the left side, and colon and
omentum reduced:
L hemithorax: washout and drain
Defect repaired with ethibond mattress sutures.
Extended Right Hemicolectomy
Side-to-side anastomosis
Abdominal washout
Left subphrenic drain (24 Robinsons)

26. Post-Operative Course
Taken to MCCU
Did not require Inotropic support
Extubated day 1
Opened bowels day 1
Transferred to ASU day 3
On wards:
Initially some post op vomiting –resolved
Recovered without incident
Discharged home day ?

27. Key points for discussion
Management of left thoracoabdominal stab
injuries
Follow-up and management of left
diaphragmatic injuries
…………