CASE PRESENTATION
DR.ANTOINE NASTA
D.I.S.GENERAL SURGERY
D.U. LAPAROSCOPIC SURGERY
HISTORY
l 31 Y.O. ETHIOPIAN PATIENT WAS ADMITTED ON 20.10.1420 FROM E.R.WITH
THE COMPLAINT OF ABDOMINAL PAIN,VOMITING,AND FEVER FOR ABOUT ONE WEEK
AND CONSTIPATIONFOR THE LAST FIVE DAYS.
l THE PATIENT GAVE H/O L.N.T.B. DIAGNOSED
AND TREATED IN ETHIOPIA DURING HIS LAST STAY THERE
EXAMINATION
l T=38
l BP=100/80
l PR=86/MIN
l RR=26/MIN
l THE ABDOMEN WAS MILDLY DISTENDED,
WITH TENDERNESS AND SEVERE GUARDING OF THE EPIGASTRIC REGION,B.S
WERE NORMAL AND THE PR DID NOT REVEAL ANY TENDERNESS OR ANY BLEEDING
l SMALL CERVICAL LYMPHADENOPATHY WAS DETECTED IN THE RIGHT POSTERIOR GROUP.
INVESTIGATIONS
l WBC=10700
l HB.=7.7G%
l PLAT=210000
l Na=124m.mol/l
l SICKLING TEST=NEG.
l MP=NEG.
l AMYLASE-N.
l LDH=N.
l WIDAL AND WRIGHT=NEG.
l CXR:ATELECTASIS OF THE RIGHT LOWER LOBE
l ABD.X-RAY:NO SPECIFIC FINDINGS.
l PROLONGED PTT=50/30
lTHE N.G.T.PRODUCED 800 ML.IN 14 HOURS
l THE GASTROGRAFINE STUDY SHOWED STENOSIS
AT THE LEVEL OF D2,AND NO PROGRESSION OF
THE CONTRAST BEYOND THAT LEVEL
THE GASROGRAFINE STUDY SHOWED STENOSIS OF D2,AND NO PROGRESSIONOF
THE CONTRAST BEYOND THAT LEVEL
l ABD. US:MINIMAL AMOUNT OF FREE FLUID,ENLARGED SPLEEN
WITH MULTIPLE CYSTS,AND PARA AORTIC L.N. OF LARGE SIZE.
l Ct-scan :CONFIRMED THESE FINDINGS
BLOOD CULTURE :NO GROWTH
MANGEMENT
l THE FIRST IMPRESSION WAS LOCAL PERITONITIS.
MANAGEMENT:-CORRECTION OF DEHYDRATION AND HYPONATREMIA.
-NGT.
-TRIPLE ANTIBIOTIC THERAPY
-CEMITIDINE
-TRANSFUSION OF PRBC+FFP
HOSPITAL COURSE
IN 48 HOURS PATIENT IMPROVED:LESS ABD. PAIN ,PASSED FLATUS
AND STOOLS,NORMAL ELECTROLYTES…
BUT HE CONTINUED TO HAVE HIGH FEVER>38.THE ABD.EX SHOWED FULLNESS OF
THE EPIGASTRIC REGION
l THEN AN EXCISIONAL BIOPSY OF THE L.N. WAS DONE UNDER L.A..
l THE PRINT AND Z.N. COLORATION SHOWED :NUMEROUS ATYPICAL AFB
l THE HISTOLOGY SHOWED:NECROTIC LYMPHADENITIS COMPATIBLE
WITH AIDS CHANGES.
lTHE HIV SEROLOGY WAS REACTIVE…
l THE CXR.SHOWED:CONSOLIDATION OF THE RIGHT BASE
AND MICRONODULAR ASPECT OF THE LUNG PARENCHYMA…
l THE FEVER SUBSIDED AFTER STOPPING THE ANTIBIOTICS..
l PANCYTOPENIA AND MILD JAUNDICE APPEARED
l HE WAS PUT ON ANTI –TB. TREATMENT,AND TRIMETHOPRIME,AND SOON
WILL BE SHIFTED TO A SPECIALISED CENTER…
AIDS AND SURGERY
lTHE GROUP IN WHICH THE DISEASE WAS ORIGINALLY PREVALENT INCLUDED
HOMOSEXUALS,USERS OF IV-DRUGS AND RECIPIENT OF BLOOD CARRYING THE VIRUS.
l NOW THEY ALSO INCLUDE HETEROSEXUALS AND CHILDREN OF INFECTED MOTHERD.
INFECTIONS IN AIDS
l THE CLINICAL CONDITIONS OCCURING MOST OFTEN ARE THOSE NORMALLY
COMBATED BY HELPER T-CELLS (CD4) AND RELATED
TO CELL MEDIATED IMMUNE RESPONSE
(PNEUMOCYSTIC CAINII,TOXOPLASMA,CRYPTOCOCCUS..)
l THE ABDOMINAL SYMPTOMS ARE USUALLY THE RESULT OF INFECTIONS WITH:
-CMV
-MYCOBACTERIA
-SALMONELLA TYPHIMURIUM
l CMV.:CAN CAUSE ENTEROCOLITIS,
THAT CAN LEAD TO BLEEDING OR PERFORATION…
lMYCOBACTERIUM AVIUM INTRACELLULARE:DIAGNOSIS MAY BE OBTAINED
FROM:BLOOD CULTURE,AND FNAs OF LIVER AND BONE MARROW…
SURGERY MAY BE REQUIRED:
-FOR DIAGNOSIS:RETRO PERITONEAL L.N.
-SPENECTOMY(ABCESS, THROMBOCYTOPENIA)
l SALMONELLA TYPHI:MAY REQUIRE VIGOROUS ANTI-MICROBIAL THERAPY…
CHOLECYSTECTOMY MAY BE NECESSARY TO CONTROL SEPSIS PARTICULARLY IN PRESENCE OF G.S.
TUMORS IN AIDS
l THE 2 MOST FREQUENT ARE:
-KAPOSI’ SARCOMA
-NON-HODJKIN LYMPHOMA
lTHE GIT LOCALISATIONS CAN BE COMPLICATED
BY:ABD.PAIN,OBSTRUCTION, PERFORATION AND HEMORRHAGE
PULMONARY PROBLEMS
l NEO.
l INFECTIONS
INFECTIONS OF SOFT TISSUES
l PROCTOCOLITIS
l CELLULITIS
OPERATIVE MANAGEMENT
l MAJOR OP. ARE NOT OFTEN INDICATED IN AIDS PATIENTS.
l HOWEVER BIOPSY,ENDOSCOPY,CLOSED THORACOTOMY
WITH THORACIC DRAINAGE AND VASCULAR ACCES ARE FREQUENTLY REQUIRED
l IN THE EARLY STAGES OF THE DISEASE :
THE PATIENT CAN BE TREATED AS ANY OTHER PATIENT WITH SYMPTOMS AND SIGNS AND LAB.
RESULTS INDICATING THAT OPERATIVE MANAGEMENT IS REQUIRED
l LATER: THE RISK IS INCREASED,AND THE USUAL CLINICAL SIGNS OF DISEASE MAY BE LOST
ELECTIVE OP.
l EXPLORATION(MASS,PAIN..)
l SPLENECTOMY
lCHOLECYSTECTOMY(SALMONELLA,CMV)
l THE MORTALITY IS MULTIPLIED X2
EMERGENCY OP.
lINTESTINAL OBSTRUCTION
l G.I. HEMORRHAGE
l PERFORATION-PERITONITIS
l THE MORTALITY IS MULTIPLIEDX5