ACUTE MULTIMORBID PATHOLOGY - DIAGNOSIS AND TREATMENT DIFFICULTIES (CASE REPORT)

Abstract

Objectives. The frequency of strangulation in postoperative ventral hernia is described in 8% of cases. The incidence of colorectal cancer in the destruction phase, complicated with peritonitis, is reported in 20% of cases. The coexistence of these pathologies is rarely encountered and has not been presented in the literature.

The aim of the study was to present the difficulties of diagnosis and treatment in a rare concomitance, a case of acute multimorbidity with the simultaneous development of two severe surgical conditions.

Material and methods. The paper presents the simultaneous resolution of two acute surgical conditions: perforated recto-sigmoid cancer complicated with peritonitis and strangulation of the small intestine in incisional hernia, diagnosed and treated in the clinic of the Institute of Emergency Medicine, Chisinau, Republic of Moldova. Patient, 58 years old, was urgently hospitalized with severe abdominal pain. From the anamnesis, he is considered sick for 3 days. The clinical data present in the patient were: the patient's condition is serious, asymmetrically distended abdomen, the evidence of strangulated incisional hernia, positive symptoms of peritoneal irritation. Among the complex investigations that were carried out were: clinical examination; laboratory tests; abdomen X-ray; ultrasonography; native computer tomography of the abdomen.

Results. There weas established clinical data of total peritonitis and pneumoperitoneum, that were radiologically confirmed. Laboratory test results were inconclusive. The decision was made to perform emergency surgery. Intraoperatively, it was determined: in the hernial sac – a portion of strangulated jejunum with necrotic changes; fibrin-purulent liquid; in the abdominal cavity – tumor formation of the recto-sigmoid colon, with destruction and perforation. Hartman resection of the colon with colostomy application was performed, as well as resection of the necrotic segment of the jejunum within the limits of viability, with the closure of the abutments in "Second Look" and drainage of the abdomen and pelvis. The established postoperative diagnosis was: ”Malignant recto-sigmoid tumor T4N1M1 in the phase of destruction complicated with perforation and total purulent-fibrinous peritonitis. Strangulated incisional hernia with strangulation and necrosis of a portion of the jejunum. Phlegmon of the abdominal wall. Uncomplicated hydatid cyst. Macronodular liver cirrhosis. Adherent disease.” Despite a complex postoperative drug treatment, the patient died after 7 days postoepratively.

Conclusions. The phenomenon of multimorbidity is a major, progressive medico-social problem, which requires unusual, innovative approaches, assessed individually, depending on the pathologies found. The reserved prognosis of the patient appeared with the intraoperative establishment of the final diagnosis of the presence of two simultaneous acute surgical diseases. The preoperative difficulty was dictated by the overlap of the clinical picture of intestinal perforation and strangulated incisional hernia, the lack of clinical history of colorectal cancer and the late presentation of the patient.