Time was when, as a medical officer, you were instructed not to administer any pain killer to a patient presented with ACUTE ABDOMEN until a diagnosis is made and a definitive line of treatment is committed to. The reason being that this has been done in the past and the patient walked away believing that the challenge was over only to come back worse off after the effect of the analgesic has faded away. Those were the days when the time interval between the when the patient presented and surgical intervention was very short. And again those were the days when very strong opiate agonists like MORPHINE, PETHIDINE, and HYDROXYCODEINE etc. were readily available and not abused.
But lately, a lot of not too sound expediency has crept into the management of surgical abdominal lesions. It is not uncommon that a patient presents with acute appendicitis; and when told would request for pain killers to ameliorate the symptoms while goes to prepare for the surgery. It is almost a general trend now and quite a few pay dearly for it.
A couple of weeks ago, a man aged 45 years old was referred to a surgical health facility. He had been with a caregiver for two weeks who had agreed with him to manage him conservatively. In other words, giving him antibiotics and analgesics, hoping that the pains would subside and surgery deferred to a later date. Unfortunately, this was not to be as the pain persisted. The abdomen distended and tensed; and the man’s fever just wouldn’t subside.
After examining the patient, the expression on the surgeon’s face was that of an alarm. The relations who were apparently surprised thought that they had come for a review while the surgeon was sending for his anaesthetist.
When eventually they opened up the abdomen, the findings were not palatable to behold. About two litres of foul smelling pus gushed out of the peritoneal cavity together with about 500 milliliter that was evacuated by the suctioning machine. The intestinal loops were mottled and friable. There was hardly anything the surgeon could do. To experienced operators the best one could do in a situation like this is to put drains for peritoneal fluid to pass through and watch events. Trying to mobilise friable bowel would be very dangerous in this condition. And that was what the surgeon did.
Within the first 24 hours after the precedure, the fever crashed and the patient was looking less toxic. But wait for it. By the fourth post-operative day, there was this massive draining of faecal smelling fluid from the wound site. It was obvious that the patient had FAECAL FISTULA. A faecal fistula is a tract connecting a ruptured site in the intestine and an outlet on the skin or any other organ of the body. When this happens it could be very discomforting to the caregiver.
This condition can complicate other lesions varying from abdominal trauma to radiotherapy of abdominal malignancies. It is the major complication in ruptured appendix with peritonitis. When there is acute septic condition in the abdomen, both the omentum and loops of intestine migrate to ‘wall off’ the site in an attempt to prevent its spread. Thus during mobilisation, the bowel being friable can avulse and perforate. This may go unnoticed by the caregiver until a couple of days later when the leak from the lumen of the bowel is significant before the sequence of events characteristic of faecal fistula ensues.
Faecal fistula is often described depending on the output of fluid and faeculent material from the skin site. It is usually referred to as a high or low output faecal fistula. The high output fistula in this environment has a very poor prognostic outlook. This becomes commonplace if the large intestine or colon is involved resulting in colitis; inflammation of the large intestine and diarrhoea. In this condition, dehydration and electrolyte imbalance is a real threat to life and can trigger the demise of the patient. Sepsis is also a serious threat but can be successfully managed pending when the patient is stable and the administration of antibiotics reduced. One should always have the back of the mind PSEUDOMEMBRANOUS COLITIS, inflammation of the large bowel, as a complication of prolonged use of antibiotics.
The hallmark of taking care of patients with faecal fistula is fluid, nutrient and calorie management. In severe cases, the only line of management advocated, if the resources are available, is TOTAL PARENTRERAL NUTRITION (TPN). This essentially the shutting of anything through the mouth and providing all the nutrition the patient needs through the intravenous route. When this line of management is used, digestive wastes would not be produced and in the process reducing faecal production.
With adequate calorie, amino acids, fatty acids and vitamins through the intravenous route, the fistula closes up very fast so long as sepsis has been controlled and the patient is not anaemic. The preferable intravenous route usually is a central line in the JUGULAR VEIN in the neck. This aspect in the management of faecal fistula requires a lot of input from the nutritionist. This could pose a real challenge in a resource constrained environment like ours, with the experience of high mortality.
In our index case, there was deterioration due to severe anaemia with a Packed Cell Volume of 10 per cent and infection with both gram positive and negative organisms. An attempt at blood transfusion resulted in severe reaction and the procedure had to be suspended. And while thoughts were on what next to do for this gravely ill man, he succumbed.
Just when I was contemplating writing this, a call came through from a friend who is on Sabbatical leave at Ambrose Alli University, Ekpoma that her brother had a ruptured appendix at 66. The surgery had already been done but there was a complication. The abdomen was distended and some bleeding from the drain site and wound. Well, it is not uncommon that in ruptured appendix during dissection by the surgeon a vessel in the omentum may accidentally rupture. The uniqueness of omentum vessel bleed is that the blood just keeps oozing out. It is not like an arterial bleeding which is under pressure and can easily call the attention of the surgeon. Again the response of omentum vessel to Platelet plug is slow.
In other word, post operative bleeding in appendicectomy is a known complication that may require the surgeon visiting the wound again. The good news was the blood clot was evacuated and the patient transfused and got better.
Thanks to Dr J Immonikhe for inspiring this.