Manoj Nair

Japan's Kansai region, already famous worldwide for its cultural landmarks and tourism hotspots such as Osaka, Kyoto, and Kobe is now gaining

This case highlights the multidisciplinary coordination required to manage perforation peritonitis in a young patient with disseminated tuberculosis, undiagnosed human immunodeficiency virus (HIV), and hemophagocytic lymphohistiocytosis (HLH). A 29-year-old woman presented to the hospital at midnight in septic shock, requiring inotropic support. Collateral history revealed a one-year history of significant weight loss. On examination, the patient appeared cachectic with a grossly distended and tender abdomen. CT imaging showed free fluid, locules of free air, and clustered small bowel loops in the mid-abdomen. Following resuscitation in line with the sepsis-6 protocol, the patient underwent emergency laparotomy. Intraoperatively, matted and dusky small bowel loops were observed, along with 2.5 litres of purulent fluid and widespread white nodules on both visceral and parietal peritoneal surfaces. A damage control approach was adopted: the abdomen was extensively lavaged, biopsies were taken, and drains were inserted, while bowel dissection was deliberately avoided to prevent further injury. Cultures later confirmed atypical mycobacteria and polymicrobial flora. Histology demonstrated caseating granulomas, and further testing revealed newly diagnosed HIV with a high viral load and a severely depleted CD4 count. In the postoperative period, the patient developed migrating enterocutaneous fistulas, which were managed through an intestinal failure protocol alongside anti-tuberculosis therapy. A concurrent diagnosis of HLH delayed the initiation of antiretroviral therapy, necessitating a carefully sequenced treatment approach. Despite the high predicted mortality and complexity of presentation, the patient gradually improved, transitioned to oral feeding, regained weight, and resumed full-time work within a year. This case underscores the importance of early damage control surgery, prompt microbiological and histological sampling, and coordinated multidisciplinary care. Lessons from this case may help inform the management of similarly complex presentations in time-critical and resource-constrained settings.

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Early postoperative endoscopic evaluation after repair of a perforated gastroduodenal ulcer is rarely performed due to concerns regarding disruption of the surgical closure. We report a patient who underwent primary sutured repair with omental reinforcement for a prepyloric ulcer perforation and subsequently developed postoperative anemia without an identifiable source of bleeding. Initial imaging, including computed tomography angiography, revealed no evidence of active arterial bleeding, prompting a carefully planned endoscopic evaluation in the third postoperative week. Endoscopy demonstrated an intact suture line with healthy granulation tissue and visible intraluminal Vicryl sutures, without evidence of bleeding or dehiscence. This case highlights that early postoperative endoscopic assessment can be safely performed when clinically indicated and provides valuable insight into the intraluminal healing process following oversewn ulcer perforation repair.

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