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Perforation peritonitis with large encysted gallstone in right nephric space report of a case
PERFORATION
PERITONITIS
WITH LARGE ENCYSTED GALLSTONE IN RIGHT NEPHRIC SPACE REPORT OF A CASE NATHAN BLAUSTEIN, M.D. NEW YORK INTRODUCTION
P
ERFORATION of the gaII bIadder or the biIe ducts must aIways be serious, on account of an escape of the viscera1 contents into the peritonea1 cavity; the danger depending, however, on two factors: first, the nature of the extravasated ffuid, and second, the time eIapsed before surgical rehef is afforded. The presence of heaIthy biIe in the peritoneum due to an injury such as a stab, a buIIet wound, or a bIow in a heahhy individua1, may be toIerated for some time without serious damage. It is of far more serious moment when the extravasated bile is pathoIogica1 as it usuaIIy is where there is distention of the gal1 bIadder or any disease of the biIe ducts; for in such cases the biIe is infectious and rapidIy sets up a diffuse peritonitis, which, unless speedily operated on, ends fataIIy. If, however, the diagnosis be made at once and early operation is done, the prognosis is good. In rupture of the gaI1 bIadder from sudden pressure induced by straining at stool, vomiting, sneezing, efforts in parturition, or even by blows over the hepatic region, there is, in a11 probabihty, in the greater number of cases a predisposition to rupture from thinning by ukeration or by Iongcontinued distention, otherwise the accident wouId be much more common. UsuaIIy perforation occurs ~10~1~. It is highly dangerous to permrt patients with distended gaII bladders to go without operation even though symptoms be onIy occasionah?; present. A careful operation
in these cases is aImost but rupture is hazardous
devoid of risk, in the extreme.
INClDENCE BiIe peritonitis occurs under various conditions, among which must be inchrded contusions of the abdomen with or without previous disease of the Iiver and larger biIe channeIs, Iacerations of the biliary tract through incised wounds of the abdomen, and, IinaIIy, both acute and chronic inflammations of the bile channels, obstructive and non-obstructive. In this paper, bile peritonitis wiI1 be considered onIy as resuIting from perforation of the gal1 bladder foIlowing a Iong-standing cholecystitis with choIeIithiasis. McWi Iliams ( I 9 I 2) cohected I 08 reports of operations where spontaneous perforation of the gaI1 bladder or extrahepatic ducts had occurred after long-standing inflammatory disease with resuIting peritonitis in aI1. This finding is sharplv at variance wrth the usual resuIt in -infections of the gall bIadder, nameIy, IocaI adhesions with a circumscribed pericholecystic abscess in which the gall bladder undergoes necrosis. McWiIIiams reviewed a total of 3 I 80 operations on the bihary tract where perforation was encountered in twenty-nine (0.9 per cent). Ka ruIIon’s figures from an analysis of 61 I 4 consecutive autopsies are somewhat higher. He found gaIIstones 372 times with perforations of the gaI1 bladder in three instances (I .5 per cent). His findings are contrary to the generahy accepted idea that the gal1 bladder is the most common site of perforation.
586
American
Journal
of Surgery
BIaustein-Perforation
From the above anaIysis it wouId seem that perforation of some portion of the biIiary system into the peritonea1 cavity occurs approximateIy once in every I00 cases of infection of the tract where the biIe ffow encounters obstruction. It is, however, a IamentabIe fact that surgica1 textbooks tend to minimize the possibiIity in the mind of the reader. SIGNS
AND
SYMPTOMS
The symptoms of perforation of the biIe passages are those of the perforative peritonitis from other causes, but there wiI1 usuaIIy have been premonitory symptoms pointing to the origin of the disease. I. Pain. A sudden pain beneath the right ribs, and coIIapse succeeded by vomiting, genera1 distention of the abdomen, and a feebIe puIse, form the prominent features of the disease. The cIinica1 appIication of dur knowIedge of the nerve suppIy of the parieta1 peritoneum depends upon the various ways in which irritation of the nerve terminaIs may be made known. Such irritation may be evidenced by (I) IocaI pain and sensitiveness; (2) referred pain; (3) superficia1 hyperesthesia; (4) superficia1 hyperaIgesia; (5) muscuIar rigidity; (6) aIteration of muscuIar reff exes. The manifestations depend partIy upon the nature of the irritant. 2. Free Fluid. If the extravasation is extensive there wiI1 be signs of free fluid in the peritonea1 cavity. Whatever be the cause, the disease usuaIIy manifests itseIf somewhat suddenIy, with pain on the right side of the abdomen, rapidIy becoming generaI. A rapid and feebIe puIse, faI1 of bIood pressure, quick thoracic breathing, fever, intense depression, paIIor, marked tenderness on pressure, rapidIy deveIoping tympanitis, vomiting, and an extremeIy anxious expression of countenance, are usuaIIy present. AIthough an eIevation of temperature is usua1, it is by no means constant, and affords onIy sIight assistance in the diagnosis or prognosis.
Peritonitis
JUNE.
1927
3. Jaundice may or may not be present; if not present before the accident, usuaIIy comes on from absorption of biIiary pigment by the peritoneum, and if the bowels can be moved, the motions wiI1 usuaIIy be cIay-coIored. The diagnosis of perforation of gaI1 bIadder is materiaIIy visuarized by a history of definite prerupture symptoms. The foIIowing are cIassica1: (I) Definite reff ex symptoms referred to the stomach at fairIy definite periods, usuaIIy within thirty minutes after eating, with marked quaIitative food dyspepsia caused by retention of gas-producing and greasy foods in the stomach constituting so-caIIed “dyspepsia” with pyIorospasm. (2) Less severe pain and more proIonged soreness after speIIs aid the diagnostician since it is probabIe that stones are either not present or are too Iarge to obstruct the duct. DIAGNOSIS
AND
DIFFERENTIAL
DIAGNOSIS
The diagnosis of peritonitis resuIting from rupture of gangrenous ChoIecystitis with Iithiasis practicaIIy resoIves itseIf into the diagnosis of the cause of acute peritonitis starting on the right side of the abdomen. AIthough this may be due to perforation of the stomach, the duodenum or the ascending coIon, etc., the chief affection for which it is IikeIy to be mistaken is acute appendicitis. In some cases, the norma descent of the cecum into the right iIiac fossa does not take pIace, the cecum and coIon, with being found in the right the appendix, hypochondrium in cIose reIation to the gaI1 bIadder. A few cases have been recorded in which this reIation was present, and an attack of appendicitis Ied to the deveIopment of an abscess beneath the right Costa1 margin. Such a case wouId give rise to great diffIcuIties, and it might be impossibIe to say unti1 the abdome? is opened whether the condition is due to ChoIecystitis or to appendicitis. In appendicitis, the pain usuaIIy begins around the umbilicus, and is subsequentIy referred to the right iIiac fossa, or it may start at a Iower point in
NEW SERIES
VOL.
II, No. 6
BIaustein-Perforation
the abdomen and pass toward the umbiIithere cus. In gall-bIadd er inflammations is aImost invariabIy tenderness a IittIe above and to the right of the umbiIicus. The symptoms of acute peritonitis and paraIytic obstruction of the boweIs are common to both. FortunateIy, exploratory incision is appropriate to both; but it is importa.nt to distinguish between them, for if the incision is made over the gaI1 bladder in a case of appendicitis, or viceversa, an abscess may be opened through the unaffected peritoneum, and give rise to genera1 peritonitis.
Peritonitis
American
JOU~II~I of Surgery
587
the peritonea1 cavity with saIine soIution as many stiI1 practice. The patient may be too iI to bear a proIonged operation (generaIIy he is), and if so, free drainage wiI1 probabIy do a11 that is necessary under the circumstances. In draining, it shouId be borne in mind that the right kidney pouch forms a distinct peritoneai pocket, and that a drainage tube appIied through a stab opening in the right Ioin affords a free exit for extravasted fluid coming from the neighborhood of the gaII bIadder. A simiIar stab wound may be made above the pubis to drain the pouch of DougIas.
PROGNOSIS
In peritonitis from diseases of the gaI1 bIadder or biIe ducts the effusion is at first Iimited to the Iarger pouch on the right side of the abdomen. These cases are, therefore, amenabIe to treatment if operated on within a short time of the catastrophe, whereas in case of deIay the ffuid, which is infective, tends to pass into the pelvis and to produce genera1 infection of the peritoneum. Prognosis is thus entireIy dependent upon the time interva1 of non-interference duringwhich theperitonitis-spreadinginfection is in progress. Other factors directIy dependent upon the time interva1 are: I. Extent of peritonea1 invoIvement. 2. Amount of intra-abdomina1 hemorrhage. 3. GaIlstones, their presence and number and whether Iocated and removed. 4. The patient’s resistance. 5. Judgment and surgica1 skiI1. 6. InvoIvement of other organs (paraIysis of gut, Iiver abscess, etc.). TREATMENT
As soon as it is cIearIy made out that perforation has occurred, or even if it be suspected that such is the case, the abdomen shouId be opened in the right semiIunar Iine. If pus and biIe be found, they should be rapidly aspirated. It is advisabIe not to use gauze sponges to wipe away any of the exudate or Ieakage; nor to ffush
FIG. I Section of large pure cholesterin caIcuIus. Arrows point to areas of softening with nests of pathogenic microorganisms. CASE
REPORT
E. R., white, aged forty years, physician, married, was admitted to the Beth David HospitaI, November 8, 1925, compIaining of sIight pain in the right side of the abdomen. For severa years he had had dyspepsia and heart-burn irreguIarIy and at Iong intervaIs. Bicarbonate of soda gave him ampIe reIief and he used it quite freeIy and reguIarIy. Five days before admission, Iate at night, he ate a spiced beef sandwich and a piece of cake; then he retired feeIing weI1. Three hours Iater he was awakened by a severe, Iancinating pain in the epigastrium which Iasted the rest of the night. The folIowing morning he was taken to BeIIevue HospitaI, where he was toId that the condition of his gaI1 bIadder necessitated immediate operation. For two days he persistentIy refused operation. Meantime
588
American Journal of Surgery
BIaustein-Perforation
vomiting appeared and the temperature and p&e rate began to rise. He was then removed from BeIIevue to Beth David HospitaI. He was then in considerable pain and was vomiting freeIy. His body and extremities were covered with a coId perspiration and the recta1 temperature was 101 OF., puIse 110, respirations, 2%; face was Iivid and somewhat cyanosed; teeth in poor condition. Lungs were negative; heart sounds, reguIar but weak. The abdomen was distended, especially the right half, and tenderness was general, more marked over the right hypochondriac region where a definite circuIar fluctuating mass couId be made out. The entire right haIf of the abdomen was rigid, and duI1 on percussion. DigitaI examination re$eaIed baIIooning of the rectum. BIood pressure was 108/70. The urine contained a trace of aIbumin and occasiona Ieucocytes. BIood examination showed a Ieucocytosis of 14,800 on November 8, faIIing to g6oo on November 13. Preopera-
URETERAL UreteraI caIcuIus on the right side, may very cIoseIy resemble pyeIitis in its symptoms, and therefore differs from appendicitis in the same respects. The pain with calcuIus may be more intense than that
Peritonitis
JUNE, IW.,
tive diagnosis was perforation of gal1 bIadder with circumscribed abscess. For five days the patient persistentIy refused operation, then consented. Operation: November 13, 1925, 8~30 A.M. Novocaine infiItration, right upper rectus incision. Peritoneum, adherent throughout to underIying mass, was incised for I inch without attempting to separate adhesions. A fouIsmelling, greenish, thick pus poured out of the wound and with the aid of suction apparatus it was compIeteIy evacuated. I found that the gaI1 bIadder has compIeteIy sloughed away. The fluid-tract extended down to the iliac region. GentIe search for stones with one finger reveared one free in the peritonea1 cavity. (see iIIustration). The abdomen was quickly cIosed with sufficient drainage. The patient faiIed to raIIy and died November 14, 8:oo P.M. The pus showed baciIIus coIi communisAjn pure cuIture.
CALCULUS with appendicitis, and the patient is bathed in perspiration, especiaIIy over the upper lip. This Iast condition is rather characteristic of uretera caIcuIus.-JOHN M. BIRNIE in Boston M. and S. J.
PERITONITIS
WITH LARGE ENCYSTED GALLSTONE IN RIGHT NEPHRIC SPACE REPORT OF A CASE NATHAN BLAUSTEIN, M.D. NEW YORK INTRODUCTION
P
ERFORATION of the gaII bIadder or the biIe ducts must aIways be serious, on account of an escape of the viscera1 contents into the peritonea1 cavity; the danger depending, however, on two factors: first, the nature of the extravasated ffuid, and second, the time eIapsed before surgical rehef is afforded. The presence of heaIthy biIe in the peritoneum due to an injury such as a stab, a buIIet wound, or a bIow in a heahhy individua1, may be toIerated for some time without serious damage. It is of far more serious moment when the extravasated bile is pathoIogica1 as it usuaIIy is where there is distention of the gal1 bIadder or any disease of the biIe ducts; for in such cases the biIe is infectious and rapidIy sets up a diffuse peritonitis, which, unless speedily operated on, ends fataIIy. If, however, the diagnosis be made at once and early operation is done, the prognosis is good. In rupture of the gaI1 bIadder from sudden pressure induced by straining at stool, vomiting, sneezing, efforts in parturition, or even by blows over the hepatic region, there is, in a11 probabihty, in the greater number of cases a predisposition to rupture from thinning by ukeration or by Iongcontinued distention, otherwise the accident wouId be much more common. UsuaIIy perforation occurs ~10~1~. It is highly dangerous to permrt patients with distended gaII bladders to go without operation even though symptoms be onIy occasionah?; present. A careful operation
in these cases is aImost but rupture is hazardous
devoid of risk, in the extreme.
INClDENCE BiIe peritonitis occurs under various conditions, among which must be inchrded contusions of the abdomen with or without previous disease of the Iiver and larger biIe channeIs, Iacerations of the biliary tract through incised wounds of the abdomen, and, IinaIIy, both acute and chronic inflammations of the bile channels, obstructive and non-obstructive. In this paper, bile peritonitis wiI1 be considered onIy as resuIting from perforation of the gal1 bladder foIlowing a Iong-standing cholecystitis with choIeIithiasis. McWi Iliams ( I 9 I 2) cohected I 08 reports of operations where spontaneous perforation of the gaI1 bladder or extrahepatic ducts had occurred after long-standing inflammatory disease with resuIting peritonitis in aI1. This finding is sharplv at variance wrth the usual resuIt in -infections of the gall bIadder, nameIy, IocaI adhesions with a circumscribed pericholecystic abscess in which the gall bladder undergoes necrosis. McWiIIiams reviewed a total of 3 I 80 operations on the bihary tract where perforation was encountered in twenty-nine (0.9 per cent). Ka ruIIon’s figures from an analysis of 61 I 4 consecutive autopsies are somewhat higher. He found gaIIstones 372 times with perforations of the gaI1 bladder in three instances (I .5 per cent). His findings are contrary to the generahy accepted idea that the gal1 bladder is the most common site of perforation.
586
American
Journal
of Surgery
BIaustein-Perforation
From the above anaIysis it wouId seem that perforation of some portion of the biIiary system into the peritonea1 cavity occurs approximateIy once in every I00 cases of infection of the tract where the biIe ffow encounters obstruction. It is, however, a IamentabIe fact that surgica1 textbooks tend to minimize the possibiIity in the mind of the reader. SIGNS
AND
SYMPTOMS
The symptoms of perforation of the biIe passages are those of the perforative peritonitis from other causes, but there wiI1 usuaIIy have been premonitory symptoms pointing to the origin of the disease. I. Pain. A sudden pain beneath the right ribs, and coIIapse succeeded by vomiting, genera1 distention of the abdomen, and a feebIe puIse, form the prominent features of the disease. The cIinica1 appIication of dur knowIedge of the nerve suppIy of the parieta1 peritoneum depends upon the various ways in which irritation of the nerve terminaIs may be made known. Such irritation may be evidenced by (I) IocaI pain and sensitiveness; (2) referred pain; (3) superficia1 hyperesthesia; (4) superficia1 hyperaIgesia; (5) muscuIar rigidity; (6) aIteration of muscuIar reff exes. The manifestations depend partIy upon the nature of the irritant. 2. Free Fluid. If the extravasation is extensive there wiI1 be signs of free fluid in the peritonea1 cavity. Whatever be the cause, the disease usuaIIy manifests itseIf somewhat suddenIy, with pain on the right side of the abdomen, rapidIy becoming generaI. A rapid and feebIe puIse, faI1 of bIood pressure, quick thoracic breathing, fever, intense depression, paIIor, marked tenderness on pressure, rapidIy deveIoping tympanitis, vomiting, and an extremeIy anxious expression of countenance, are usuaIIy present. AIthough an eIevation of temperature is usua1, it is by no means constant, and affords onIy sIight assistance in the diagnosis or prognosis.
Peritonitis
JUNE.
1927
3. Jaundice may or may not be present; if not present before the accident, usuaIIy comes on from absorption of biIiary pigment by the peritoneum, and if the bowels can be moved, the motions wiI1 usuaIIy be cIay-coIored. The diagnosis of perforation of gaI1 bIadder is materiaIIy visuarized by a history of definite prerupture symptoms. The foIIowing are cIassica1: (I) Definite reff ex symptoms referred to the stomach at fairIy definite periods, usuaIIy within thirty minutes after eating, with marked quaIitative food dyspepsia caused by retention of gas-producing and greasy foods in the stomach constituting so-caIIed “dyspepsia” with pyIorospasm. (2) Less severe pain and more proIonged soreness after speIIs aid the diagnostician since it is probabIe that stones are either not present or are too Iarge to obstruct the duct. DIAGNOSIS
AND
DIFFERENTIAL
DIAGNOSIS
The diagnosis of peritonitis resuIting from rupture of gangrenous ChoIecystitis with Iithiasis practicaIIy resoIves itseIf into the diagnosis of the cause of acute peritonitis starting on the right side of the abdomen. AIthough this may be due to perforation of the stomach, the duodenum or the ascending coIon, etc., the chief affection for which it is IikeIy to be mistaken is acute appendicitis. In some cases, the norma descent of the cecum into the right iIiac fossa does not take pIace, the cecum and coIon, with being found in the right the appendix, hypochondrium in cIose reIation to the gaI1 bIadder. A few cases have been recorded in which this reIation was present, and an attack of appendicitis Ied to the deveIopment of an abscess beneath the right Costa1 margin. Such a case wouId give rise to great diffIcuIties, and it might be impossibIe to say unti1 the abdome? is opened whether the condition is due to ChoIecystitis or to appendicitis. In appendicitis, the pain usuaIIy begins around the umbilicus, and is subsequentIy referred to the right iIiac fossa, or it may start at a Iower point in
NEW SERIES
VOL.
II, No. 6
BIaustein-Perforation
the abdomen and pass toward the umbiIithere cus. In gall-bIadd er inflammations is aImost invariabIy tenderness a IittIe above and to the right of the umbiIicus. The symptoms of acute peritonitis and paraIytic obstruction of the boweIs are common to both. FortunateIy, exploratory incision is appropriate to both; but it is importa.nt to distinguish between them, for if the incision is made over the gaI1 bladder in a case of appendicitis, or viceversa, an abscess may be opened through the unaffected peritoneum, and give rise to genera1 peritonitis.
Peritonitis
American
JOU~II~I of Surgery
587
the peritonea1 cavity with saIine soIution as many stiI1 practice. The patient may be too iI to bear a proIonged operation (generaIIy he is), and if so, free drainage wiI1 probabIy do a11 that is necessary under the circumstances. In draining, it shouId be borne in mind that the right kidney pouch forms a distinct peritoneai pocket, and that a drainage tube appIied through a stab opening in the right Ioin affords a free exit for extravasted fluid coming from the neighborhood of the gaII bIadder. A simiIar stab wound may be made above the pubis to drain the pouch of DougIas.
PROGNOSIS
In peritonitis from diseases of the gaI1 bIadder or biIe ducts the effusion is at first Iimited to the Iarger pouch on the right side of the abdomen. These cases are, therefore, amenabIe to treatment if operated on within a short time of the catastrophe, whereas in case of deIay the ffuid, which is infective, tends to pass into the pelvis and to produce genera1 infection of the peritoneum. Prognosis is thus entireIy dependent upon the time interva1 of non-interference duringwhich theperitonitis-spreadinginfection is in progress. Other factors directIy dependent upon the time interva1 are: I. Extent of peritonea1 invoIvement. 2. Amount of intra-abdomina1 hemorrhage. 3. GaIlstones, their presence and number and whether Iocated and removed. 4. The patient’s resistance. 5. Judgment and surgica1 skiI1. 6. InvoIvement of other organs (paraIysis of gut, Iiver abscess, etc.). TREATMENT
As soon as it is cIearIy made out that perforation has occurred, or even if it be suspected that such is the case, the abdomen shouId be opened in the right semiIunar Iine. If pus and biIe be found, they should be rapidly aspirated. It is advisabIe not to use gauze sponges to wipe away any of the exudate or Ieakage; nor to ffush
FIG. I Section of large pure cholesterin caIcuIus. Arrows point to areas of softening with nests of pathogenic microorganisms. CASE
REPORT
E. R., white, aged forty years, physician, married, was admitted to the Beth David HospitaI, November 8, 1925, compIaining of sIight pain in the right side of the abdomen. For severa years he had had dyspepsia and heart-burn irreguIarIy and at Iong intervaIs. Bicarbonate of soda gave him ampIe reIief and he used it quite freeIy and reguIarIy. Five days before admission, Iate at night, he ate a spiced beef sandwich and a piece of cake; then he retired feeIing weI1. Three hours Iater he was awakened by a severe, Iancinating pain in the epigastrium which Iasted the rest of the night. The folIowing morning he was taken to BeIIevue HospitaI, where he was toId that the condition of his gaI1 bIadder necessitated immediate operation. For two days he persistentIy refused operation. Meantime
588
American Journal of Surgery
BIaustein-Perforation
vomiting appeared and the temperature and p&e rate began to rise. He was then removed from BeIIevue to Beth David HospitaI. He was then in considerable pain and was vomiting freeIy. His body and extremities were covered with a coId perspiration and the recta1 temperature was 101 OF., puIse 110, respirations, 2%; face was Iivid and somewhat cyanosed; teeth in poor condition. Lungs were negative; heart sounds, reguIar but weak. The abdomen was distended, especially the right half, and tenderness was general, more marked over the right hypochondriac region where a definite circuIar fluctuating mass couId be made out. The entire right haIf of the abdomen was rigid, and duI1 on percussion. DigitaI examination re$eaIed baIIooning of the rectum. BIood pressure was 108/70. The urine contained a trace of aIbumin and occasiona Ieucocytes. BIood examination showed a Ieucocytosis of 14,800 on November 8, faIIing to g6oo on November 13. Preopera-
URETERAL UreteraI caIcuIus on the right side, may very cIoseIy resemble pyeIitis in its symptoms, and therefore differs from appendicitis in the same respects. The pain with calcuIus may be more intense than that
Peritonitis
JUNE, IW.,
tive diagnosis was perforation of gal1 bIadder with circumscribed abscess. For five days the patient persistentIy refused operation, then consented. Operation: November 13, 1925, 8~30 A.M. Novocaine infiItration, right upper rectus incision. Peritoneum, adherent throughout to underIying mass, was incised for I inch without attempting to separate adhesions. A fouIsmelling, greenish, thick pus poured out of the wound and with the aid of suction apparatus it was compIeteIy evacuated. I found that the gaI1 bIadder has compIeteIy sloughed away. The fluid-tract extended down to the iliac region. GentIe search for stones with one finger reveared one free in the peritonea1 cavity. (see iIIustration). The abdomen was quickly cIosed with sufficient drainage. The patient faiIed to raIIy and died November 14, 8:oo P.M. The pus showed baciIIus coIi communisAjn pure cuIture.
CALCULUS with appendicitis, and the patient is bathed in perspiration, especiaIIy over the upper lip. This Iast condition is rather characteristic of uretera caIcuIus.-JOHN M. BIRNIE in Boston M. and S. J.