Santol Seed Causing Intestinal Perforation - OMMC Surgery - March 27, 2015

DEPARTMENT OF SURGERY

OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”



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A Continuing Advocacy




Swallowed Santol Seeds (SS) Causing

Surgical Abdomen

Janix M. De Guzman, MD, FPCS, FPSGS

Glenn P. Villanueva, MD

Marienelle R. Maulion, MD



An Advocacy for Preventable Surgical

Abdomen and Premature Death

In 2001, the OMMC Department of Surgery

started the advocacy to educate the public and

other health professionals and later create

awareness on the potential public health

problem that swallowing of Santol seed impose.









“The Case of the Deadly Santol Seeds”

by Dr. Rafael Castillo of the Philippine Daily Inquirer

published in 2001






According to Dr. Joson, “the

debilitation and deaths associated

with swallowing santol seeds have

reached such magnitude to

consider it a public health

problem”

The OMMC surgical

department has

started

disseminating

information about

the dangers of

swallowing santol

seeds.

Obstruction in the large

intestine with a hole or

perforation just before

the obstruction. Several

santol seeds were

found lodged in that

area.






Primary Prevention

• Creation of awareness of the danger of

swallowing the seeds

• Promote a habit not to swallow the seeds at all cost






Secondary Prevention

• Prevent the morbidity and mortality

associated with swallowed santol seeds.






“Please Don’t Swallow Santol Seeds, they could

be deadly” October 10, 2002






Posted as a public health advisory in the OMMC

website in 2003






“Men Over Forty” Deadly Santol Seedsby Dr. Eduardo Gatchalian of the Manila Times

published in 2004






“Don’t Swallow Santol Seeds” by Dr. Willie T. Ong published in The Philippine Star,

July 20, 2010






“Enjoy the Fruit But Not the Seeds” by Dr. Eduardo Gonzales published in the Manila

Bulletin last 2013











Ostomy News Notes

Vol.1 Issue2, page7

May-Aug 2012






Review of Literature

- 6 journal articles = www

– Ramirez, Carlo G, Crisostomo A, Gutierrez, Romeo, Roxas A. Colonic Perforation Associated with “Santol” Seeds. Asian Journal of Surgery;Colorectal Surgery 1993;16 (3):232-5.

– Velayo B, DobleF, Delos Santos N, Talens E. Ten Cases of Intestinal Obstruction and/or Perforation Associated with Ingestion of Fruit Seeds. PJSS. 1998








– Leyson O, Penserga E, Joson R. Swallowed “ Santol” Seeds As Cause of Surgical Abdomen – A Case Report. Unpublished. 2002

– Samboonpamya P. Sigmoid colon perforation by ingested Sandorica Seeds. J Med Assoc, Thai. 2001 Dec; 84(12):1751-3








– Anan M, Boonchai N, Suphakarn T, Busaba S. Gastrointestinal Complications from Ingested Santol Seeds. The THAI Journal of SURGERY 2004; 25:91-112.

– Chaw S, Pranee S, Supaluk K. Non-traumatic Perforation of Colon: A 5-year Retrospective Study at Uthaithani Hospital. The THAI Journal of SURGERY 2009; 30:52-57.




OMMC Statistics




0

1

2

3

4

5

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Nu

mb

er

of

Cas

es

Number of Cases per Year




0

10

31-40 41-50 51-60 61-70 71-80

Age Distribution of Cases




0

5

10

Male

Female

Sex Distribution of Cases




0

10

Distribution per Month






Anan, et al.

-Survey. Knowledge and Behaviour

-1601 General Surgeons of Thai Medical Council

-2880 Adults. Random Sample Population.

-Respondents:

-37.2% of 1601 GS

-29.9% had encountered cases of SSS

-34.2% of 2880 RSP

-56.6% did not know complication of SSS

-41.2% ingested santol seed






Public Health Education:

• The public should be told what to do when

Santol seeds are unintentionally swallowed.

• They have to watch out for abdominal pain

and seek consult as soon as possible to

avoid late diagnosis of surgical abdomen due to intestinal perforation.






• Death from swallowed santol seeds and

operations done in these patients should be

considered unnecessary because the

etiology is totally preventable and the death is considered premature.






• Early diagnosis can be promoted by a

knowledge that surgical abdomen can be

caused by swallowed santol seeds as well as

by a high index of suspicion in patients who

have swallowed santol seeds and a surgical

abdomen occurring during the season

months of santol, from July to October in the Philippines.






THANK YOU!






N. G.

39-year-old Male

Malate, Manila






ABDOMINAL PAIN

RIGHT LOWER QUADRANT

AREA




Chief Complaint

One Day PTC






History of Present IllnessAbdominal pain, RLQ

Area, Colicky in

character, 6/10 in

severity

(+)anorexia

(+)fever(T 38.0˚C)

(+)post-prandial

vomiting, 3 episodes

No consult done

No medications taken

On the day of

consult






History of Present IllnessIncrease in severity of

pain to 10/10

Prompted consult at

our institution






Review of Systems

No headache, tinnitus, no blurring of vision, no

sore throat

No cough, no difficulty of breathing, no

shortness of breath

No easy fatigability, no palpitations, no chest

pain

No frequency, no urgency, no hematuria, (+)

dysuria

No polyuria, no polyphagia, no polydipsia

No weakness, no seizures, no loss of

consciousness






Past Medical History

(+) Benign Prostatic Hypertrophy, recently

diagnosed maintained in Tamsulosin

200mg/tab ODHS

(+) S/P Herniorrhaphy, Right

(ManilaMed, Medical Center Manila, 1998 )

No Hypertension, Bronchial Asthma

No Diabetes Mellitus, Pulmonary Tuberculosis,

No Allergies to food and medications






Family History

No Hypertension, Bronchial Asthma,

Diabetes Mellitus, Pulmonary Tuberculosis,

Cerebrovascular Disease, Cancer






Personal / Social History

Smoker, 5 pack years

Alcoholic beverage drinker (2-3 bottles of beer,

2 drinking session per week)

Methamphetamine drug use






Physical Examination

Vital Signs:

General:

SHEENT:

BP: 120/90 HR: 95 RR: 23 T: 38.0

O2Sat: 99%

Awake, coherent, not in

cardiorespiratory distress

Good skin turgor, anicteric sclerae,

pink palpebral conjunctivae, no

nasoaural discharge, no cervical

lymphadenopathy, flat neck veins







Chest and

Lungs:

Heart:

Abdomen:

Symmetric chest expansion, no

retractions, clear breath sounds

Adynamic precordium, normal rate,

regular rhythm, no murmurs

Flabby, Non-distended,

Normoactive bowel sounds,

(+) Direct tenderness on right lower

quadrant more than the

hypogastric area







Abdomen:

Flabby, Non-distended,

Normoactive bowel

sounds,

(+) Direct tenderness

on right lower

quadrant more than

the hypogastric area







DRE:

Extremities:

No anal tags or fissures, No

hemorrhoids, good sphincteric

tone, non-collapsed rectal vault,

no mass or tenderness, (+) fecal

material on examining finger

Grossly normal, no edema, no

cyanosis, full pulses






Pre-treatment Diagnosis

Acute Surgical Abdomen probably

secondary to Ruptured Appendicitis




120/90

95

23

38.0

NPO

IVF: D5LRS 1L to run at 125 cc/hr

Therapeutics:

• Cefuroxime 1.5gm TIV

• Metronidazole 500mg TIV q8

• Ranitidine 50mg TIV q8

• Paracetamol 300mg TIV now

Book to OR for “E” Appendectomy

Emergency Room




Emergency Room

CBC

WBC 23.7

Neutrophil 87.7

Lymphocyte 3.3

Monophil 8.6

Eosinophil 0.2

Basophil 0.2

RBC 4.51

Hemoglobin 15.2

Hematocrit 43.3

MCV 96

MCH 33.6

MCHC 35

Platelet 369

URINALYSIS

Color Amber

Transparency Turbid

Epithelial cell Occasional

Mucus thread Few

Amorphous

urates

Many

Amorphous

phosphates

None

WBC 10-15

RBC Many

Albumin None

Sugar None

SG -

pH -

Bacteria Moderate

Yeast cells None

Waxy casts None

Coarse Granular

Cast

None



Intra-operative FindingsTransverse Right

Lower Quadrant

Incision

• Grossly normal

appendix

• Fecal seepage

coming from the

pelvic area






Intra-operative FindingsFull midline Ex-Lap

Incision






Intra-operative Findings

• Sigmoid colon

perforation with

noted

• Localized fecal

peritonitis




Full midline Ex-Lap Incision



Procedure

Transverse Right

Lower Quadrant

Incision converted to

Exploratory

Laparotomy,

Hartmann’s Procedure







130/80

104

22

36.5

(-) Colostomy

output

Soft

Abdomen,

Tender only in

the operative

site

1st Post-op Day

NPO


Therapeutics:

• Shift to Pip-Tazo 4.5gm TIV q8



• Ketorolac 30mg TIV q8 PRN

• Paracetamol 300mg TIV PRN

IFC

Course in the wards




120/80

90

19

36.9

(-) Colostomy

output

Soft abdomen

Tender only

on post-

operative site

2nd Post-op Day

Soft Diet


Therapeutics:

• Pip-Tazo 4.5gm TIV q8





Remove IFC

Course in the wards




120/80

72

17

36.8

(+) Colostomy

output

Soft abdomen

Tender only

on post-

operative site

3rd Post-op Day

Soft Diet to DAT

IVF to consume

Therapeutics:

• Cefuroxime 500mg/cap TID

• Metronidazole 500mg/cap TID

• Mefenamic Acid 500mg/cap q8

PRN

Course in the wards




120/90

84

18

36.5

(+) Colostomy

output

Soft abdomen

Tender only

on post-

operative site

4th Post-op Day

DAT

Therapeutics:




PRN

May ambulate

Course in the wards




130/90

84

20

36.5

(+) Colostomy

output

Soft abdomen

Tender only

on post-

operative site

5th Post-op Day

DAT

May go home

Therapeutics:




PRN

Course in the wards


OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”FINAL DIAGNOSIS

Gangrenous colitis, ruptured, sigmoid

colon

Planes of resection, viable




Histopathologic Diagnosis



Acute Surgical Abdomen secondary to

Localized Fecal Peritonitis secondary to

Sigmoid Perforation secondary to

Santol Seed Ingestion




Final Diagnosis








J.E.

53-year-old Female

Tondo, Manila






GENERALIZED ABDOMINAL

PAIN




Chief Complaint

Five Days PTC






History of Present IllnessAbdominal pain,

Crampy, Generalized

8/10 in severity

(+) Fever (T 38.6˚C)

No consult done

No medications taken

One Day PTC






History of Present IllnessIncrease in severity of

pain to 10/10

Prompted consult at

our institution






Review of Systems

No headache, tinnitus, no blurring of vision, no

sore throat

No cough, no difficulty of breathing, no

shortness of breath

No easy fatigability, no palpitations, no chest

pain

No frequency, no urgency, no hematuria, no

dysuria, no polyuria, no polyphagia, no

polydipsia

No weakness, no seizures, no loss of

consciousness






Past Medical History

No Hypertension, Bronchial Asthma

No Diabetes Mellitus, Pulmonary Tuberculosis,

No Allergies to food and medications






Family History

No Hypertension, Bronchial Asthma,

Diabetes Mellitus, Pulmonary Tuberculosis,

Cerebrovascular Disease, Cancer






Personal / Social History

Smoker, 10 pack years

Non-alcoholic beverage drinker







Vital Signs:

General:

SHEENT:

BP: 140/80 HR: 85 RR: 22 T: 36.5

O2Sat: 99%

Awake, coherent, not in

cardiorespiratory distress

Good skin turgor, anicteric sclerae,

pink palpebral conjunctivae, no

nasoaural discharge, no cervical

lymphadenopathy, flat neck veins







Chest and

Lungs:

Heart:

Abdomen:

Symmetric chest expansion, no

retractions, clear breath sounds

Adynamic precordium, normal rate,

regular rhythm, no murmurs

Slightly distended, hypoactive

bowel sounds,

(+) Direct tenderness on left upper

and lower quadrant with

involuntary muscle guarding







Abdomen:

Slightly distended,

hypoactive bowel

sounds,


on left upper and

lower quadrant

with involuntary

muscle guarding







DRE:

Extremities:

No anal tags or fissures, No

hemorrhoids, good sphincteric

tone, non-collapsed rectal vault,

no mass or tenderness, (+) fecal

material on examining finger

Grossly normal, no edema, no

cyanosis, full pulses






Pre-treatment Diagnosis


Perforated Viscus




150/80

94

20

36.9

NPO

NGT inserted and kept open

IVF: PNSS 1L to run at 125 cc/hr

Therapeutics:

• Ceftriaxone 1gm TIV q8



• Paracetamol 300mg TIV now

IFC

Book to OR for Ex-Lap

Emergency Room




Emergency Room

CXR PA Upright:

• Pneumoperitoneum




Emergency Room

PFA Upright:

• Ileus




Emergency Room

CBC

WBC 17.9

Neutrophil 88.4

Lymphocyet 5.9

Monocyte 2.7

Eosinophil 2.1

Basophil 0.9

RBC 4.81

Hemoglobin 12.1

Hematocrit 37.9

MCV 78.9

MCH 25.1

MCHC 31.8

Platelet 439

Urinalysis

Color Dark Yellow

Transparency Clear

Epithelial cell Few

Mucus thread Occasional

Amorphous

Urates

Occasional

Amorphous

Phosphates

None

WBC 2-4

RBC 0-2

Albumin +2

Sugar Negative

SG 1.020

pH 5.0

Bacteria Moderate




Emergency Room

Clin Chem

BUN 9.9

Crea 0.61

Na 136

K 4.2



Procedure

Full midline

Exploratory Laparotomy

Incision






Intra-operative Findings

• Perforated

diverticula on the

Sigmoid colon with

noted Santol seed

on the diverticulum

• Several Santol

seeds were also

noted on the

Sigmoid

• Generalized fecal

peritonitis






Procedure

Hartmann’s Procedure







100/60

77

18

36.5

(-) Colostomy

Output

Soft abdomen

Tender only

on post-

operative site

1st Post-op Day

NPO


Therapeutics:

• Shift to Pip-Tazo 4.5gm TIV q8





IFC

Course in the wards




120/80

90

19

36.9

(-) Colostomy

Output

Soft abdomen

Tender only

on post-

operative site

2nd Post-op Day

NPO


Therapeutics:

• Pip-Tazo 4.5gm TIV q8





Remove IFC

Course in the wards




120/80

72

17

36.8

(+) Colostomy

output

Soft abdomen

Tender only

on post-

operative site

3rd Post-op Day

Soft Diet

IVF: D5NM 1L to run at 100ccc/hr

Therapeutics:



• Celecoxib 200mg/cap q12 PRN

for Pain

Course in the wards




120/90

84

18

36.5

(+) Colostomy

output

Soft abdomen

Tender only

on post-

operative site

4th Post-op Day

DAT

IVF to consume

Therapeutics:



• Celecoxib 200mg/cap q12 PRN

for Pain

May ambulate

Course in the wards




130/90

84

20

36.5

(+) Colostomy

output

Soft abdomen

Tender only

on post-

operative site

5th Post-op Day

DAT

May go home

Therapeutics:




PRN

Course in the wards



Acute on chronic peridiverticulitis,

Congestion and Hemorrhage with

rupture, Sigmoid Colon

Planes of resection, viable tissues




Histopathologic Diagnosis




Generalized Fecal Peritonitis secondary

to Perforated Diverticulitis secondary

to Santol Seed Ingestion




Final Diagnosis











CASE 1 CASE 2

AGE 39 53

SEX MALE FEMALE

PRESENTING

SYMPTOMS

• Abdominal Pain

• Sudden

• Abdominal Pain

• Gradual

Comparison of the 2 Cases






CASE 1 CASE 2

ABDOMINAL

FINDINGS

• Flabby, Non-

distended,

Normoactive bowel

sounds,

• (+) Direct

tenderness on right

lower quadrant

more than the

hypogastric area

Flabby, Non-

distended,

Normoactive bowel

sounds,


on left upper and

lower quadrant with

involuntary muscle

guarding






CASE 1 CASE 2

INTRA-OP

FINDINGS

• Sigmoid colon

perforation with

noted Santol seeds

• Localized fecal

peritonitis

• Perforated

diverticula on the

Sigmoid colon with

lodged Santol seed

• Generalized fecal

peritonitis






CASE 1 CASE 2

HISTO-

PATHOLO

GIC

• Gangrenous

colitis, ruptured,

Sigmoid Colon

• Planes of

resection, viable

• Acute on chronic

peridiverticulitis,

Congestion and

Hemorrhage with

rupture, Sigmoid

Colon

• Planes of resection,

viable




FACTS FROM PREVIOUS STUDIES




“The presence of hard stool or a foreign body

like santol seeds can cause pressure necrosis

ulceration and perforation of the bowels.”

Ramirez, Carlo G, Crisostomo Armando, Gutierrez, Romeo, Roxas Alberto. Colonic

Perforation Associated with “Santol” Seeds. Asian Journal of Surgery;Colorectal

Surgery 1993;16 (3):232-5.




• Distal colon have relatively poor blood supply

• Fecal content become dehydrated in the

distal colon

• Sigmoid and the rectosigmoid can generate high intraluminal pressure

Ramirez, Carlo G, Crisostomo Armando, Gutierrez, Romeo, Roxas Alberto. Colonic

Perforation Associated with “Santol” Seeds. Asian Journal of Surgery;Colorectal

Surgery 1993;16 (3):232-5.






“Bangkok Santol seeds, which are bigger and

have sharper ends, the most common adverse

event seems to be primary perforation even in the absence of structural defect in the colon.”




What is the pathophysiology?






OBSTRUCTION CAUSED BY SANTOL SEEDS

THEORY 1: DIVERTICULUM

LODGE OF THE SANTOL SEED ON A

DIVERTICULUM

PUNCTURE OF THE DIVERTICULAR WALL BY THE

SHARP END OF THE SEED






THEORY 1: DIVERTICULUM






OBSTRUCTION CAUSED BY SANTOL SEEDS

THEORY 2: NORMAL BOWEL

DILATATION OF THE COLON

PRESSURE NECROSIS AND PUNCTURE OF THE

BOWEL WALL BY THE SHARP END OF THE SEED






THEORY 2: NORMAL BOWEL






THANK YOU!

Health & Medicine

Santol Seed Causing Intestinal Perforation - OMMC Surgery - March 27, 2015