Postgraduate Medicine
ISSN: 0032-5481 (Print) 1941-9260 (Online) Journal homepage: http://www.tandfonline.com/loi/ipgm20
Spontaneous Perforation of Umbilical Hernia With Ascites Stephen Alan Imbeau To cite this article: Stephen Alan Imbeau (1975) Spontaneous Perforation of Umbilical Hernia With Ascites, Postgraduate Medicine, 57:3, 187-191, DOI: 10.1080/00325481.1975.11714001 To link to this article: http://dx.doi.org/10.1080/00325481.1975.11714001
Published online: 07 Jul 2016.
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Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ipgm20 Download by: [Australian Catholic University]
Date: 13 August 2017, At: 09:19
Downloaded by [Australian Catholic University] at 09:19 13 August 2017
SPONTANEOUS PERFORATION OF UMBILICAL HERNIA WITH ASCITES A 63-year-old man was hospitalized for the third time for treatment of ascites of one year's duration. Diuretic therapy and salt restriction had partially controlled the condition. The patient had a history of heavy use of alcohol over many years and of gastrointestinal blood loss that had been treated with iron taken orally. He wore a T binder to prevent soilage from fecal incontinence that had developed after a hemorrhoidectomy on a previous admission. The patient appeared to be chronically ill. Blood pressure was 110/70 mm Hg, pulse rate was 80 beats per minute, respirations were 20 per minute, and temperature was normal. The skin was dry and thin; spider angioma and gynecomastia were noted. Dupuytren's contracture was pccent bilaterally. A grade 2/6 systolic murmur was heard at the left sterna! border. The abdomen was tense, and a fluid wave was easily shown. The skin overlying an umbilical hernia was ulcerated and macerated, the testes were atrophic, and slight pitting edema of the lower extremities was noted. Results of laboratory studies were as follows: blood urea nitrogen (BUN) 28 mg/100 ml, glucose 107 mg/100 ml, creatinine 1.2 mg/100 ml, sodium 126 mEq/liter, potassium 5.5 mEq/ !iter, chloride 96 mEq/liter, venous carbon dioxide 21 mEq/liter, total protein 6.8 gm/100 ml, albumin 3.5 gm/100 ml, total bilirubin 0.77 mg/100 ml, alkaline phosphatase 127 mU/ml, lactic dehydrogenase 168 mU/ml, serum glutamic oxalacetic transaminase 16 mU/ ml, and hematocrit reading 32%. Spironolactone and hydrochlorothiazide were given to induce diuresis.
Vol. 57 • No. 3 • March 1975 • POSTGRADUATE MEDICINE
case report
STEPHEN ALAN IMBEAU, MD University of Wisconsin Hospitals Madison
On the ninth hospital day, the umbilical hernia spontaneously perforated, with loss of about 10 liters of fluid (23-lb loss in weight and 22-cm reduction in abdominal girth). Therapy with Ringer's lactate, saline, and albumin solutions was given, and 24 hours later the laboratory values were: sodium 123 mEq/ !iter, potassium 5.5 mEq/liter, chloride 99 mEq/ !iter, venous carbon dioxide 14.3 mEq/liter, BUN 16 mg/100 ml, albumin 2.9 gm/100 ml, and creatinine 1.3 mg/100 ml. The umbilical tear was treated with compression bandages. Twenty-four hours after umbilical perforation, localized cellulitis developed, which was successfully treated with 2.4 million units of penicillin G given intravenously over the first 24 hours and then with penicillin V potassium salts, 1 gm/day orally for eight days. The patient remained afebrile and ascitic fluid cultures remained sterile. The patient's condition stabilized rapidly, and diuretic therapy was continued. At follow-up examination after nine months, he was doing well. Discussion
Spontaneous perforation of umbilical hernia is an unusual, but often fatal, complication of (Continued on page 189)
187
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Case Report
DIAGNOSIS: Certain manifestations of diabetes mellitus are revealed in these photographs: (A) fundus shows neovascularization and marked retinal scarring (male, age 23); (B) biopsy of kidney shows early diabetic intercapillary glomerulosclerosis (male, age 35); (C) photos 1 & 2 show edema and loss of the plantar arch (female, age 59); (D) lateral x-ray (same patient) shows dropped arch and hypertrophic and destructive changes of tarsal and metatarsal joints (Charcot's arthropathy); (E) AP confirms hypertrophic and destructive changes in (D). Please see complete product information, a summary of which follows: Each Berocca Tablet contains: Thiamine mononitrate (Vitamin BJ) ............... 15 mg Riboflavin (Vitamin B 2 ) . . 15 mg Pyridoxine HCl (Vitamin B 6 ).. . . 5 mg Niacinamide ................. 100 mg Calcium pantothenate. . . . . . . . 20 mg Cyanocobalamin (Vitamin B 12 ) . . 5 mcg Folic acid. . . . . . . . . . . . . . . . . . 0.5 mg Ascorbic acid (Vitamin C) ...... 500 mg
Indications: Nutritional supplementation in conditions in which watersoluble vitamins are required prophylactically or therapeutically. Warning: Not intended for treatment of pernicious anemia or other primary or secondary anemias. Neurologic involvement may develop or progress, despite temporary remission of anemia, in patients with pernicious anemia who receive more than 0.1 mg of folic acid per day and who are inadequately treated with vitamin B 12. Dosage: 1 or 2 tablets daily, as indicated by clinical need. Available: In bottles of 100.
®
ROCHE LABORATORIES Division of Hoffmann-La Roe he I ne. Nutley. NewJersey07110
hepatic cirrhosis. Fifteen cases of pedoration with ascites have been reported in the literature.1-9 In two cases the outcome was not specified; of the remaining 13 patients, however, only five survived. The causes of death are complex, but often include some combination of renal failure, electrolyte imbalance, pulmonary edema, and peritonitis. One patient died from massive hematemesis after umbilical herniorrhaphy.t Salt and albumin solutions were given to all 15 patients as emergency therapy. The immediate effects of spontaneous perforation are similar to those of large-volume paracentesis. Rapid removal of large amounts of ascitic fluid is known to result in vascular collapse and in severe electrolyte imbalance. 10 •11 Albumin and fluid rapidly reaccumulate in the peritoneal cavity after paracentesis, at the expense of the intravascular space.U·~2 Renal failure is often a consequence. The ability to withstand these hemodynamic and biochemical aberrations appears to correlate positively with survival. Two procedures for umbilica,l repair have been reported: simple bandage compression and herniorrhaphy. Criteria for selecting either repair procedure are not clear, but the prognosis is grave regardless of the method used. To my knowledge, the patient presented here is the first reported who has survived with simple umbilical compression. Five patients who had hemiorrhaphy survived, but these numbers are too small for statistical comparison. One patient who had undergone portacaval shunt obtained good resolution of the ascites and lived for at least three years. 7 Judd and Heimburger6 and Tracy and associates 7 used this case as evidence that creation of a portacaval shunt is definitive therapy for umbilical hernia perforation, but Flood4 reported a patient who had spontaneous umbilical perforation one year after having a portacaval shunt. The umbilical leak must not be allowed to persist, because of problems with continuing loss of ascitic fluid and with peritonitis. Only one of seven patients has been reported to have survived peritonitis. In six of the patients, ascitic fluid cultures revealed the presence of Staphylococcus aureus; in the remaining patient, both Proteus vulgaris and a Gram-positive coccus (Continued on page 191)
189
Case Report
Downloaded by [Australian Catholic University] at 09:19 13 August 2017
EACH SINGLET CONTAINS: 40 mg. phenylephrine hydrochloride 8 mg. chlorpheniramine maleate 500 mg. acetaminophen
INDICATIONS: Singlet is indicated for the symptomatic treatment of colds, sinusitis, allergic rhinitis, and influenza complicated by congestion, rhinorrhea, fever, headache, myalgia and other painful states.
CONTRAINDICATIONS: Hypersensitivity to any of the formula ingredients.
PRECAUTIONS: Singlet contains a sympathomimetic agent and should be used cautiously in individuals with severe hypertension, diabetes mellitus, hyperthyroidism or urinary retention. The antihistaminic agent may cause drowsiness, and ambulatory patients who operate machinery or motor vehicles should be cautioned accordingly.
DOSAGE AND ADMINISTRATION: Adults, one Singlet tablet three or four times daily. The interval between doses, however. should not be less than six hours, and not more than one Singlet should be taken at one time. To assure continuous release of medication, do not break or crush tablets.
were present. One patient died of peritonitis in spite of penicillin and streptomycin prophylaxis. Eight of the 15 patients with spontaneous umbilical perforation whose cases are reported in the literature had antecedent injury to the umbilical skin. In the patient whose case is presented here, the skin was injured by the T binder. Baron1 and others have suggested that perforation occurs when abdominal pressure suddenly increases. These case results would seem to indicate that injured skin overlying an already defective area of abdominal wall is a potential site of rupture. Hence, the umbilical skin of patients with ascites should be cat:efully protected against trauma. Address reprint requests to Stephen A1an Imbeau, MD, Department of Medicine, University of Wisconsin Hospitals, 1300 University Ave, Madison, WI 53706.
REFERENCES 1. Baron HC: Umbilical hernia secondary to cirrhosis of the liver. N Engl 1 Med 263:824, 1960 2. Eisenberg MM, Hoye S1: Spontaneous perforation of umbilical hernia. Arch Surg 81:514, 1960 3. I.erner S, Rost MS: Spontaneous abdominal paracentesis. 1AMA 255:1310, 1959 4. Flood FB: Spontaneous perforation of the umbilicus in Laennec's cirrhosis with massive ascites. N Engl 1 Med 264:72, 1961 S. Schairer AE, Cox LM, Keeley 11: Spontaneous perforation of umbilical hernia in cirrhosis of the liver. Am 1 Surg 106:94, 1963 6. 1udd DR, Heimburger IL: Spontaneous rupture of an umbilical hernia due to massive ascites. 1 Indiana State Med Assoc 59:1431, 1966 7. Tracy GD, Reeve TS, Thomas ID, et a!: Spontaneous umbilical rupture in portal hypertension with • massive ascites. Ann Surg 161:623, 1965 8. Yonemoto RH, Davidson CS: Herniorrhaphy in cirrhosis of the liver with ascites. N Engl 1 Med 255:733, 1956 9. Bynum TE, Smalley TK: Rupture of ascites umbilical hernia during esophagoscopy. Gastrointest Endosc 17:67, 1970 10. Gabuzda G1 1r, Trager HS, Davidson CS: EHects of sodium chloride administration and restriction, and of abdominal paracentesis on electrolyte and water balance. 1 Oin Invest 33:780, 1954 11. Heher R, Sherlock S: Electrolyte and circulatory changes in terminal liver failure. Lancet 2:1121, 1956 12. Rothschild MA, Oratz M, Schreiber SS: Albumin synthesis. N Engl 1 Med 286:748, 816, 1972
PosTGRADUATE
......y..
MEDICINE invites submission of brief case reports for early publication. Illustrations and references should be included only when essential.
DOW PHARMACEUTICALS The Dow Chem1cal Company lnd1anapolls. lnd 46268
191
ISSN: 0032-5481 (Print) 1941-9260 (Online) Journal homepage: http://www.tandfonline.com/loi/ipgm20
Spontaneous Perforation of Umbilical Hernia With Ascites Stephen Alan Imbeau To cite this article: Stephen Alan Imbeau (1975) Spontaneous Perforation of Umbilical Hernia With Ascites, Postgraduate Medicine, 57:3, 187-191, DOI: 10.1080/00325481.1975.11714001 To link to this article: http://dx.doi.org/10.1080/00325481.1975.11714001
Published online: 07 Jul 2016.
Submit your article to this journal
View related articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ipgm20 Download by: [Australian Catholic University]
Date: 13 August 2017, At: 09:19
Downloaded by [Australian Catholic University] at 09:19 13 August 2017
SPONTANEOUS PERFORATION OF UMBILICAL HERNIA WITH ASCITES A 63-year-old man was hospitalized for the third time for treatment of ascites of one year's duration. Diuretic therapy and salt restriction had partially controlled the condition. The patient had a history of heavy use of alcohol over many years and of gastrointestinal blood loss that had been treated with iron taken orally. He wore a T binder to prevent soilage from fecal incontinence that had developed after a hemorrhoidectomy on a previous admission. The patient appeared to be chronically ill. Blood pressure was 110/70 mm Hg, pulse rate was 80 beats per minute, respirations were 20 per minute, and temperature was normal. The skin was dry and thin; spider angioma and gynecomastia were noted. Dupuytren's contracture was pccent bilaterally. A grade 2/6 systolic murmur was heard at the left sterna! border. The abdomen was tense, and a fluid wave was easily shown. The skin overlying an umbilical hernia was ulcerated and macerated, the testes were atrophic, and slight pitting edema of the lower extremities was noted. Results of laboratory studies were as follows: blood urea nitrogen (BUN) 28 mg/100 ml, glucose 107 mg/100 ml, creatinine 1.2 mg/100 ml, sodium 126 mEq/liter, potassium 5.5 mEq/ !iter, chloride 96 mEq/liter, venous carbon dioxide 21 mEq/liter, total protein 6.8 gm/100 ml, albumin 3.5 gm/100 ml, total bilirubin 0.77 mg/100 ml, alkaline phosphatase 127 mU/ml, lactic dehydrogenase 168 mU/ml, serum glutamic oxalacetic transaminase 16 mU/ ml, and hematocrit reading 32%. Spironolactone and hydrochlorothiazide were given to induce diuresis.
Vol. 57 • No. 3 • March 1975 • POSTGRADUATE MEDICINE
case report
STEPHEN ALAN IMBEAU, MD University of Wisconsin Hospitals Madison
On the ninth hospital day, the umbilical hernia spontaneously perforated, with loss of about 10 liters of fluid (23-lb loss in weight and 22-cm reduction in abdominal girth). Therapy with Ringer's lactate, saline, and albumin solutions was given, and 24 hours later the laboratory values were: sodium 123 mEq/ !iter, potassium 5.5 mEq/liter, chloride 99 mEq/ !iter, venous carbon dioxide 14.3 mEq/liter, BUN 16 mg/100 ml, albumin 2.9 gm/100 ml, and creatinine 1.3 mg/100 ml. The umbilical tear was treated with compression bandages. Twenty-four hours after umbilical perforation, localized cellulitis developed, which was successfully treated with 2.4 million units of penicillin G given intravenously over the first 24 hours and then with penicillin V potassium salts, 1 gm/day orally for eight days. The patient remained afebrile and ascitic fluid cultures remained sterile. The patient's condition stabilized rapidly, and diuretic therapy was continued. At follow-up examination after nine months, he was doing well. Discussion
Spontaneous perforation of umbilical hernia is an unusual, but often fatal, complication of (Continued on page 189)
187
Downloaded by [Australian Catholic University] at 09:19 13 August 2017
Case Report
DIAGNOSIS: Certain manifestations of diabetes mellitus are revealed in these photographs: (A) fundus shows neovascularization and marked retinal scarring (male, age 23); (B) biopsy of kidney shows early diabetic intercapillary glomerulosclerosis (male, age 35); (C) photos 1 & 2 show edema and loss of the plantar arch (female, age 59); (D) lateral x-ray (same patient) shows dropped arch and hypertrophic and destructive changes of tarsal and metatarsal joints (Charcot's arthropathy); (E) AP confirms hypertrophic and destructive changes in (D). Please see complete product information, a summary of which follows: Each Berocca Tablet contains: Thiamine mononitrate (Vitamin BJ) ............... 15 mg Riboflavin (Vitamin B 2 ) . . 15 mg Pyridoxine HCl (Vitamin B 6 ).. . . 5 mg Niacinamide ................. 100 mg Calcium pantothenate. . . . . . . . 20 mg Cyanocobalamin (Vitamin B 12 ) . . 5 mcg Folic acid. . . . . . . . . . . . . . . . . . 0.5 mg Ascorbic acid (Vitamin C) ...... 500 mg
Indications: Nutritional supplementation in conditions in which watersoluble vitamins are required prophylactically or therapeutically. Warning: Not intended for treatment of pernicious anemia or other primary or secondary anemias. Neurologic involvement may develop or progress, despite temporary remission of anemia, in patients with pernicious anemia who receive more than 0.1 mg of folic acid per day and who are inadequately treated with vitamin B 12. Dosage: 1 or 2 tablets daily, as indicated by clinical need. Available: In bottles of 100.
®
ROCHE LABORATORIES Division of Hoffmann-La Roe he I ne. Nutley. NewJersey07110
hepatic cirrhosis. Fifteen cases of pedoration with ascites have been reported in the literature.1-9 In two cases the outcome was not specified; of the remaining 13 patients, however, only five survived. The causes of death are complex, but often include some combination of renal failure, electrolyte imbalance, pulmonary edema, and peritonitis. One patient died from massive hematemesis after umbilical herniorrhaphy.t Salt and albumin solutions were given to all 15 patients as emergency therapy. The immediate effects of spontaneous perforation are similar to those of large-volume paracentesis. Rapid removal of large amounts of ascitic fluid is known to result in vascular collapse and in severe electrolyte imbalance. 10 •11 Albumin and fluid rapidly reaccumulate in the peritoneal cavity after paracentesis, at the expense of the intravascular space.U·~2 Renal failure is often a consequence. The ability to withstand these hemodynamic and biochemical aberrations appears to correlate positively with survival. Two procedures for umbilica,l repair have been reported: simple bandage compression and herniorrhaphy. Criteria for selecting either repair procedure are not clear, but the prognosis is grave regardless of the method used. To my knowledge, the patient presented here is the first reported who has survived with simple umbilical compression. Five patients who had hemiorrhaphy survived, but these numbers are too small for statistical comparison. One patient who had undergone portacaval shunt obtained good resolution of the ascites and lived for at least three years. 7 Judd and Heimburger6 and Tracy and associates 7 used this case as evidence that creation of a portacaval shunt is definitive therapy for umbilical hernia perforation, but Flood4 reported a patient who had spontaneous umbilical perforation one year after having a portacaval shunt. The umbilical leak must not be allowed to persist, because of problems with continuing loss of ascitic fluid and with peritonitis. Only one of seven patients has been reported to have survived peritonitis. In six of the patients, ascitic fluid cultures revealed the presence of Staphylococcus aureus; in the remaining patient, both Proteus vulgaris and a Gram-positive coccus (Continued on page 191)
189
Case Report
Downloaded by [Australian Catholic University] at 09:19 13 August 2017
EACH SINGLET CONTAINS: 40 mg. phenylephrine hydrochloride 8 mg. chlorpheniramine maleate 500 mg. acetaminophen
INDICATIONS: Singlet is indicated for the symptomatic treatment of colds, sinusitis, allergic rhinitis, and influenza complicated by congestion, rhinorrhea, fever, headache, myalgia and other painful states.
CONTRAINDICATIONS: Hypersensitivity to any of the formula ingredients.
PRECAUTIONS: Singlet contains a sympathomimetic agent and should be used cautiously in individuals with severe hypertension, diabetes mellitus, hyperthyroidism or urinary retention. The antihistaminic agent may cause drowsiness, and ambulatory patients who operate machinery or motor vehicles should be cautioned accordingly.
DOSAGE AND ADMINISTRATION: Adults, one Singlet tablet three or four times daily. The interval between doses, however. should not be less than six hours, and not more than one Singlet should be taken at one time. To assure continuous release of medication, do not break or crush tablets.
were present. One patient died of peritonitis in spite of penicillin and streptomycin prophylaxis. Eight of the 15 patients with spontaneous umbilical perforation whose cases are reported in the literature had antecedent injury to the umbilical skin. In the patient whose case is presented here, the skin was injured by the T binder. Baron1 and others have suggested that perforation occurs when abdominal pressure suddenly increases. These case results would seem to indicate that injured skin overlying an already defective area of abdominal wall is a potential site of rupture. Hence, the umbilical skin of patients with ascites should be cat:efully protected against trauma. Address reprint requests to Stephen A1an Imbeau, MD, Department of Medicine, University of Wisconsin Hospitals, 1300 University Ave, Madison, WI 53706.
REFERENCES 1. Baron HC: Umbilical hernia secondary to cirrhosis of the liver. N Engl 1 Med 263:824, 1960 2. Eisenberg MM, Hoye S1: Spontaneous perforation of umbilical hernia. Arch Surg 81:514, 1960 3. I.erner S, Rost MS: Spontaneous abdominal paracentesis. 1AMA 255:1310, 1959 4. Flood FB: Spontaneous perforation of the umbilicus in Laennec's cirrhosis with massive ascites. N Engl 1 Med 264:72, 1961 S. Schairer AE, Cox LM, Keeley 11: Spontaneous perforation of umbilical hernia in cirrhosis of the liver. Am 1 Surg 106:94, 1963 6. 1udd DR, Heimburger IL: Spontaneous rupture of an umbilical hernia due to massive ascites. 1 Indiana State Med Assoc 59:1431, 1966 7. Tracy GD, Reeve TS, Thomas ID, et a!: Spontaneous umbilical rupture in portal hypertension with • massive ascites. Ann Surg 161:623, 1965 8. Yonemoto RH, Davidson CS: Herniorrhaphy in cirrhosis of the liver with ascites. N Engl 1 Med 255:733, 1956 9. Bynum TE, Smalley TK: Rupture of ascites umbilical hernia during esophagoscopy. Gastrointest Endosc 17:67, 1970 10. Gabuzda G1 1r, Trager HS, Davidson CS: EHects of sodium chloride administration and restriction, and of abdominal paracentesis on electrolyte and water balance. 1 Oin Invest 33:780, 1954 11. Heher R, Sherlock S: Electrolyte and circulatory changes in terminal liver failure. Lancet 2:1121, 1956 12. Rothschild MA, Oratz M, Schreiber SS: Albumin synthesis. N Engl 1 Med 286:748, 816, 1972
PosTGRADUATE
......y..
MEDICINE invites submission of brief case reports for early publication. Illustrations and references should be included only when essential.
DOW PHARMACEUTICALS The Dow Chem1cal Company lnd1anapolls. lnd 46268
191
