Unusual post-operative complication after total hysterectomy

Head of Department, Department of Obstetrics and Gynaecology, Adichunchanagiri Institute of Medical Science, Rajiv Gandhi University of Health Science, Bangalore, India Professor,Department of Surgery, Adichunchanagiri Institute of Medical Science, Rajiv Gandhi University of Health Science, Bangalore, India Assistant professor,Department of Obstetrics and Gynaecology, Adichunchanagiri Institute of Medical Science, Rajiv Gandhi University of Health Science, Bangalore, India Post Graduate, Department of Obstetrics and Gynaecology, Adichunchanagiri Institute of Medical Science, Rajiv Gandhi University of Health Science, Bangalore, India


Introduction
Hysterectomy are done for many reasons starting from the AUB being the most commonest. Hysterectomies are not far from complications like any other surgeries. Bowel perforation is one of the rarest of those.

Case report
A 50 year old P4L4 A1 tubectomised patient came with the complain of bleeding per vagina since 3 months which was preceded by 2 months of amenorrhea.
The bleeding lasted for 3-4 days followed by gap of 4-5 days .Patient uses 2-3 pads/ day. She didn't have any history of passage of clots. She is a known case of rheumatoid arthritis on treatment of prednisolone 20 mg BD since last 6 years.
On per abdominal examination a mass of corresponding to 14 weeks gravid uterus was felt and mass was firm inconsistency, smooth surface regular margins, and mobile in horizontal direction with lower border cannot be made out, uterine anterior wall fibroid of 7x7cm.
On per vaginal examination uterus was corresponding to 12 wks size. Bilateral fornix were free. Ultra sound report showed uterine size of 12x10x10 cm with anterior wall fibroid of 8x8cm.
Steroid was tapered to prednisolone 10 mg OD and inj hydrocortisone 100mg from 1 day prior to surgery. Anemia of 7 hb was corrected with 2 pint of packed cells.
Total abdominal hysterectomy with bilateral oophorectomy was done. An 8x8 cm fibroid was noted on the anterior wall and numerous adhesions were found on the right adenexa and was released.
A pelvic drain was put in view of the raw surface in the right adenexa to prevent adhesion. Intra operatively there was no complications.
On the1st post-operative day pelvic drain was draining 10-15 ml reddish fluid in 24 hrs. On the second day the drain was draining 15ml of some greenish discharge.
Immediately the drained fluid was sent for analysis and it came as positive for bile pigment and salts. On the third post-operative day the drain output increased to 200 ml in 24hour and the color still continues to be greenish.
Till post-operative day 3 the patient did not had any complain. Patient has passed flatus. There was no bowel distension, abdomen was soft, and bowel sound was present. Immediately patient and patient attender were counseled.
Exploratory laparotomy was done. On opening the abdomen after extensive search 2 small ulcers of 0.5 diameters 1 cm apart was found in the jejunum. Bowel resection and end to end anastomosis was done. Patient recovered fully and stitches were removed on post op day 11 and was discharged.
On histopathology report of the specimen came as edema, congestion, and marked eosinophilic infiltration of the sub mucosa, with sloughing of the mucosa. The appearances suggested non-specific enteritis probably due to long duration of steroid intake and operative stress.

Discussion
The drain which was kept to minimize the post operative adhesion due to ooz from the raw areas was helpful in bringing to the early reorganization and detection of the jejunal ulcers which would have cause peritonitis.

Conclusion
Steroids are a boon as well a curse to the human society. Study have shown that patient with bowel perforation who were on steroid had more free peritoneal involvement , but fewer signs and symptoms of peritonitis than the nonsteroid group. 1 Perforation is not frequent as per the study done by FDA recently. Out of 1, 38, 243 patient taking perdnisolone only 2 patients had jejunal ulcer (0.00%). 2 According to the study by FDA published on Aug, 18, 2013: out of 53,186 people reported to have side effects when taking Ibuprofen only 3 people (0.01%) have Jejunal Perforation. 3 When glucocorticosteroid use and gastrointestinal perforation occur together, the most important factors for patient survival are early recognition and prompt appropriate surgical intervention.