Case report:
The patient was an 80-year-old woman who had been describing recurrent
hepatic colic for 5 years prior to her present consultation. She
consulted for right hypochondrial pain accompanied by chills. At the
examination she exhibited fever of 38.7°c, accelerated pulse to 114 bpm,
guarding circumscribed to the right hypochondrium with tenderness on the
remaining quadrants, without icterus. On biology, inflammatory markers
were increased without cholestasis. On ultrasound, the gallbladder was
thickened and 5 mm in size, with lithiasis and subhepatic and Douglas
effusion. After adequate resuscitation, patient was rushed for
exploratory laparotomy for a cholecystectomy for acute perforated
cholecystitis. The surgical approach involved a right subcutaneous
incision. The inspection revealed a generalized purulent effusion with
denses adhesions in hepatic area rendering the dissection hazardous. A
slit on the left side allowed to widen the operative incision. After
adhesiolysis and thorough washout of encountered intraperitoneal
spillage, we have identified an inflammatory intestinal-mesenteric
organization compartmentalizing a punctiform perforation at the
antemesenteric edge with sphaceous edges, oedematous intestinal wall
around the perforation and mesenteric engorgement. The bidigital
palpation found a mass that rolled over the fingers. She had a segmental
resection with transformation into a double ileostomy accompanied by
feeding jejunostomy, in the perspective of overcoming disorders
associated with a proximal ilesotomy, due to perforation located at 40cm
of the ligament of Treiz. A gallstone measuring 2cm was expressed out
from the specimen. Her postoperative progress was almost uneventful;
however, several days were required for wound healing and improvements
in daily living activities because she was frail and elderly.
Histopathological results of the intervened patient revealed isolated
jejunal perforation with ischemic edges and covered with fibrous
coating, without local inflammatory process or arteriosclerosis at the
site of perforation. There was no evidence of malignancy in the resected
specimen. She later passed away 2 months later due to major ionic
disorders.