បទបង្ហាញCPDខេត្តកណ្តាល

មន្ទរី ពេទ្យបង្អែក ជ័ យជំន្ះ
Dengue
Shock 26/08/2022
Syndrome Ang Chanratmana, MD, COP, IPPC
Objectives
➢WHO Dengue fever classification

➢How to diagnosis DF/DHF/DSS
➢How to manage DSS
➢Case discussion
Dengue classification
WHO SEARO 2011 WHO TDR 2009
(Plamsa leakage) (Warning sign)
• DF
• DHF • Dengue fever
• DSS • Dengue fever ± warning sign
• Expanded dengue • Severe dengue
syndrome
Diagnosis of Dengue Fever (DF)
➢ Fever for 2-7 days with two or more of the following symptoms:
• Headache
• Retro-orbital pain
• Myalgia
• Arthralgia
• Tender hepatomegaly
• Rash and Haemorrhagic manifestations (TT+)
▪ CBC:
➢ Leucopenia (WBC < 5,000)
➢ Hct normal or slightly elevated
➢ Platelet normal or mild decreased
➢ (>half of DF patients have thrombocytopenia)
Diagnosis of Dengue Hemorrhagic Fever (DHF
➢The following must all be present:

• Fever, or history of fever, lasting 2-7 days, occasionally biphasic.
• Haemorrhagic tendency (TT+, Petechiae, mucosal/gum bleeding)
• Thrombocytopenia < 100,000 cells per mm³
• Evidence of plasma leakage
Dengue Shock Syndrome (DSS)
➢ All the four criteria for DHF must be present, plus

▪ Evidence of circulatory failure (Shock)
o Tachycardia, weak pulse, CRT>2s
o Narrow pulse pressure (< 20mmHg) or manifested by:
• Hypotension for age, and
• Cold, clammy skin and restlessness.
Expanded Dengue Syndrome
• Unusual dengue with rare occurrence

• Unusual manifestations with
- Neurological features: encephalitis, GBS, polyneuropathy,…
- Isolated organ involvement: heart (Myocarditis), liver, renal.
• Result in organ failure.
Fluids required for IV
➢Crystalloids: ➢Colloids:
• NSS • Dextran 40
• D5 NSS • Voluven
• D5 LR • FFP (Fresh Frozen Plasma)
• D5 AR • Plasma substitute
• D51/2 NSS (Hypotonic solution,
for infants under 6 months old)
Fluid management in DHF grade I & II
➢In Critical phase, start amount

• <6 months old: D5%1/2NS 1.5-3ml/kg/h
• >6 months old: D5%NS 1.5-3ml/kg/h
➢Reassess every 3-6 hours, titrate fluid if worse.
➢Should keep 24-48 hours
Fluid management
DSS with detectable pulse and BP (DHF III)
Fluid management
DSS with detectable pulse and BP (DHF III)
Fluid management
DSS with undetectable pulse/BP (DHF IV)
Fluid management
DSS with undetectable pulse/BP (DHF IV)
Monitoring
➢Vital signs and peripheral ➢Warning signs

perfusion • Abdominal pain or tenderness
➢Urine output • Persistent vomiting
➢HCT • Clinical fluid accumulation
➢Blood glucose, electrolytes • Mucosal bleeding
• Lethargy / Restlessness
• Increase HCT in concurrent &
rapid decrease platelet.
Case
Patient information
Name : S.P.R
Sex : Female
Age : 12 years old
Address : Prek Ta Pov, Derm Mean, TaKhmao
Date of admission : 30/june/2022 at 19:00
Case
Chief complaint : Fever, abdominal pain, vomit and drowsiness
History of present illness
A 12 years old girl sick 5 days with
-High fever not response with antipyretic, associated with headache, fatigue.
-Diffuse abdominal pain, vomit ~7-8times today and mild shortness of breath,
-No malena but slightly gum bleeding.
-No fever since this morning (around10-12h), his last urine last 4h.
-Mother bought unknown PO medication from pharmacy => not better => cabinet
got blood test (WBC=3.6, Hct=48, Plat=47), IVF 6bottles/2day (3000ml) and IV drugs => weak
and drowsy => Chey Chum Nes Referral Hospital.
• Past medical history : No history hospitalized before, birth history normal
• Vaccination : Completed (national vaccination program)
• Family and social history :
- Low social-economic status,
-His brother just resolved from DF last week.
• Growth and Development : Normal by age

• Allergic : Unknown
Physical examination
30-06-22 at 19:00
Vital sign : -T°: 36.1°C -HR: 120 bpm
- RR: 24/mn -SpO2: 97% (room air)
-BP: 90/74 mmHg - weight: 26kg
• GA: look sick and drowsiness

• HEENT: Puffy eye and blood clot on the gum
• CVS : Pulse radial weak, CRT~2s,
cold extremities, HR: 120 bpm
Physical examination
• RS : Low air entry on right lung base,

no chest retraction but ↑ work of breathing
• GIS: mild distension, abdominal soft. Tender diffuse abdomen
(↑RUQ), liver palpable~3cm.
• NS : GCS 14/15, no meningeal signs
• Other: Petechiae on extremities and injection site
Primary Diagnosis : Dengue shock syndrome
Differential diagnosis:
• Hypovolemic shock
• Septic shock
Treatment
1.Admit in ER.
2.IVF D5%NSS 260ml for 1h ( 10ml/kg/h) for 1hr then reaccess.
3.Ice pack on abdomen.
4.Check CBC, CRP, glycaemia, electrolyte, calcemia, urea,
creatinine, transaminase, blood group and cross match.(urgent).
5.Check vital sign q1h and monitor urine output.
Lab result:
- WBC: 10.7 (4-10) - Glycermia : 94 (79-140)

- RBC : 6.53 (3.8-4.8) - Calcium : 8.1 (8.1-10.4)
- HB : 16.6 (12-15) - Na : 132 (135-146)
- Hct : 50.4 (36-46) -K : 3.9 (3.5-5.1)
- Mcv : 77.2 (83-101) - Cl : 102 (98-108)
- Plat : 41 (150-410) - ALT : 50 (<32)
- Neut: 6.42 (2-7) - AST : 58 (<31)
- Lym : 2.67 (1-3) - Creatinine : 0.5 (0.5-0.9)
- Mon: 0.54 (0.2-1) - CRP :6 (>12)
- Bas : 0 (0.02-0.1)
- Eos : 1 (0.02-0.5) - Blood group: B Rh(+)
Progression day 1 (30/06/2022)
20h00
• Vomit 1time Plan:
• Abdominal pain
• No active bleeding 1. IVF D5%NSS 260ml/h(10ml/kg/h) for
• Temp: 36 ⷪC, RR: 22, SpO2: 99%RA 1h.
• BP: 90/70 mmHg (90/74), Pulse: 2. Repeat CBC (urgent).
96bpm 3. Check vital sign q1h and monitor
• GA: Lethargy urine output.
• Radial pulse weak, CRT< 2s
Cool extremities
• Urine(-)
Impression: DSS not response with IVF
21h00
Plan:
• No vomit
• Abdominal pain 1. ↓ IVF D5%NSS 200ml/h (8ml/kg/h) for
• No active bleeding 2h
• Temp: 36,2 ⷪC, RR: 22, SpO2: 99%RA 2. Check Hct next 2h
• BP: 98/64 mmHg (90/70), Pulse: 89bpm 3. Check vital sign q1h and monitor urine
• GA: sleepy output
• Radial pulse normal, CRT< 2s
• Cool extremities,
• Urine(+) estimate~2.2ml/kg/h
(350ml in last 6h)
• Hct: 46, Plat: 34,
23h00
• Vomit 1time Plan:
• Abdominal pain
• No active bleeding 1. ↓ IVF D5%NSS 160ml/h (6ml/kg/h)
• Temp: 36 ⷪC, RR: 20, SpO2: 99%RA for 2h
• BP: 96/60 mmHg (98/64), Pulse: 2. Check Hct next 2h
• GA: sleepy urine output
• Radial pulse normal, CRT< 2s 4. Domperidone(10mg) 1tablet TID PO
• Cool extremities, 5. Cimetidine (200mg) 1tablet BID PO
• Urine(-) 6. ORS free
• Hct: 45
Impression: DSS response with IVF

1h00
• No vomit Plan:
• Abdominal pain
• No active bleeding 1. ↓ IVF D5%NSS 80ml/h (3ml/kg/h) for
• Temp: 36,5 ⷪC, RR: 22, SpO2: 98%RA 6h
• BP: 98/62 mmHg (96/60), Pulse: 2. Monitor Hct q4h
• GA: stable urine output
• Warm extremities,
• Mild ↑ work of breathing
• Urine(-)
• Hct: 44
Impression: DSS response with IVF
7h00
• No vomit Plan:
• Abdominal pain ↓
• No active bleeding 1. ↓ IVF D5%NSS 40ml/h (1.5ml/kg/h)
• Temp: 36,7 ⷪC, RR: 20, SpO2: 99%RA for
• BP: 102/65 mmHg, Pulse: 84bpm 2. Monitor Hct q6h
• GA: better 3. Check vital sign q4h and monitor
• Radial pulse normal, CRT< 2s urine output
• Warm extremities, 4. Repeat CBC
• Mild ↑ work of breathing 5. Abdominopleural ultrasound.
• Urine(+) 3.2ml/kg/h
(850ml in last 10h)
• Hct: 42
Impression: DSS response with IVF with
13h00
• Abdominal pain ↓ Plan:
• Itching rash on extremities
• No active bleeding 1. keep IVF D5%NSS 40ml/h (1.5ml/kg/h).
• Temp: 36,5 ⷪC, RR: 22, SpO2: 99%RA 2. Add Chlopheniramine (4mg) 1tablet TID PO
• BP: 98/60 mmHg, Pulse: 80bpm 3. Monitor Hct q8h
• GA: better, puffy eyes 4. Check vital sign q4h and monitor urine output
• Radial pulse normal, CRT< 2s 5. Move to IPD
• Mild ↑ work of breathing
• Low air entry on right lung base
• Hct: 40, Plat: 30
• Abdominal ultrasound: minimal ascites and
pleural effusion on right lung
Impression: DHF in critical-convalescence
phase with sign of fluid overload
7h00
• No fever ~48h Plan:
• Itching rash on extremities 1. Stop IVF
• No active bleeding 2. Stop check Hct
• RR: 22, SpO2: 99%RA 3. Repeat CBC tomorrow
• BP: 102/62 mmHg,
• GA: better, puffy eyes
• ↓ work of breathing
• Low air entry on right lung base
• Hct: 40, Plat: 34
Impression: DHF in convalescence

phase with sign of fluid overload
7h00
• No fever Plan:
• No difficult in breathing Discharge home 04/07/22.
• No active bleeding
• ↑ appetite
• GA: alert
• No work of breathing
• Lung sound clear, normal air
entry
• Hct: 39, Plat: 55
Impression: DHF in convalescence

phase without sign of fluid overload
References
1. National Guideline for Clinical Management of Dengue 2021.

2. Handbook for clinical management of dengue, WHO TDR 2012.
3. Comprehensive guidelines for prevention and control of dengue and dengue haemorrhagic fever,
WHO SEARO 2011.
Key Messages
➢ In Epidemic countries, patients who have high fever without

coryza, not responding to antipyretic, should be suspected to
dengue infection.
➢ Not to introduce IV fluid, if it is not necessary.
➢ Close monitoring during critical period.
Case Présentation par Dr. Sam Kdomsichan
(CPA1) Le 26-08-2022
វេជ្ជបណ្ឌិត សំ ក្តុមសុចា
៊ី ន ់
• អតីតគ្រូពេទ្យេាបាលផ្នែកជម្ងឺទ្ូពៅនៃម្ៃទីរពេទពេទ្យអផ្កគិករវរពេទ ី កគ់
ពេតតតាផ្ក ឆ្ែាំ (២០០៦-២០១០)
• អៃត ៃវកគ អញ្ចអ់ការពេទសវកាថ្នែក់ព ជជអណ្វឌ តពៅសកល ទ្ាល័ វ យ
ព ជជសាស្រសតសុខាភវបាលឆ្ែាំ២០១៥ ជាំនាៃ់ទ្ី ៣៤
• ព ើកគការពេទពារពេទៃវពកេអទ្ឆ្ែាំ ២០១៩
• អច្ចុអបៃែជាគ្រូពេទ្យេាបាលផ្នែកជម្ងឺទ្ូពៅនៃម្ៃទីរពេទពេទ្យអផ្កគិក
អកគគសួលែ ពេតតកណ្ត ត ល ចាអ់េីឆ្ែាំ ២០១៥-២០២២
Objectif
•Présentation Case Clinique
•Présentation Littérateur
Case Clinique
•Le patient âgé de 34 ans sexe masculine ,

pesant de 65kg , venant district
Angsnoul, Province de Kandal est entré
dans notre service MG le 21-06-2022 á
09h: 30mn.
Motif d'entrée
•Entrée Pour :
•Fièvre ,
•Frisson ,
•Douleur abdominale intense.
Histoire de la maladie
• Le patient à remontée depuis 1 semaine est
caractérisée par fièvre ,frisson , douleur abdominale.
Traitée à une clinique privée par les médicamentes
de type inconnue, mais son état ne s'améliorée pas .
Un jour avant d'entrée par douleur abdominale
intense , fièvre , frisson , asthénie intense. C’est le
motif d’entrée a l'hôpital.
ATCD
•Pas de notion médico-chirurgical
•Tabagisme environ 10 ans
•Alcoolisme environ 10 ans
Examen Clinique
❑Signes généraux :
•Etat général peu altérée
•Conjonctive normale
•Pouls = 112/mn
•TA = 110/75 mm de Hg
•T = 39.2°C
•RR = 24/mn
•SpO2 = 98%
Examen Clinique (suite)
❑Signes fonctionnel
•Fièvre , Frisson
•Douleur abdominal
•Nausée
❑Signes physiques
• App digestive :
• Ventre souple .
• Foie très sensible douleur à la palpation.
• Hépatomégalie (environ 2 cm sous le rebord costal droite).
• Douleur HCD intense (Signe ébranlement).
• Rate non palpable.
• Gaz (++) et selle normal .
• App urinaire:
• Urine jaune foncé
❑Signes physiques
•App cardio-vasculaire
✓BDC :Pas de bruite pathologique audible
•App Respiratoire
✓Cage thoracique symétrique
✓Douleur thoracique hémi droite
✓Pas de râle ni de souffle audible
✓MV, VV normale
•Autre appareille : RAS
Bilan Clinique
• Devant un patient âgé de 34ans présent de motif
d’entrée par douleur abdominale intense , fièvre et
frisson. ATCD alcoolisme, tabagisme. Examen
physique (Fièvre , fission , Douleur HCD intense,
Hépatalgie , Hépatomégalie, signe ébranlement .
Donc je pense probablement :

Abcès du foie?
Diagnostique différentiel :
•Cholécystite ?
•Pneumonie basal droite?
•Tumeur du foie ?
Examen Para - clinique
•Hémogramme
•Transaminase , Glycémie
•HBs-Ag, Hbs-Ac, HCV
•Echographie abdomino-pelvienne
•Radiographie pulmonaire
Résultat laboratoire
• HEMATOLOGIE (Sysmex KX-21N) Résultat Unité Valeur Normal
• Globule Blanc…………….………. :16.6 x109/L (4.0-10.0)
• Globule rouge………………………. :4.8 x1012/L (4.0-5.5)
• Hémoglobine……………………… :12.7 g/dl (11.8-18.0)
• Hématocrite………………………… :38 % (35-50)
• MCV……………………………… :85 µm3 (80-96)
• MCH…………………………………. :27 pg (27-32)
• MCHC………………………………. :36 % (32-36)
• Plaquette…………………………… :224 x109/L (140-400)
• Formule leucocytaire:
• P. neutrophil……… :75 % (40-70)
• P. éosinophile…… :05 % (01-05)
• P. Basophile……......:00 % (00-02)
• Monocyte……….. :05 % (02-10)
• Lymphocyte…… :15 % (20-40)
• Transaminase
• ASAT………………………..:48 (<45)
• ALAT………………………..:52 (<45)
• HBs-Ag …………………………: Réaction négative

• Hbs-Ac ………………………..:…: Réaction négative
• HCV :……………………….…… : Réaction négative
• Glycémie :…………………..…… : 97mg/dl (75-115)
Résultat Echographie
•Le foie est l'augmentation de la taille de
diamètre > 160mm avec les granulations de la
parenchymateux, de contour régulier, il y a
présence une collection liquidienne de 34mm
x 47mm au segment VI.
Résultat Radiologie
Résultat Radiologie ( Normal)
Diagnostique Positive
❑Selon
• Motif d’entrée
o(fièvre,frisson et douleur abdominale)
• Histoire
o(1 semaine est entrée pour fièvre, frisson, asthénie
et douleur abdominale intense)
• ATCD
o(Tabagisme et alcoolisme)
Diagnostique Positive (Suite)
• Examen Clinique
oSignes généraux (peu altérée, T=39.2ºC, Pouls=112/mn,
TA=110/75mm/Hg, RR=24/mn, SpO2=98%)
oSignes fonctionnel(fièvre, frisson, Douleur abdominal)
oSignes physique (App digestive : Douleur HCD , foie
très sensible (Hépatalgie , Signe ébranlement)
• Examen para-clinique (GB = 16.6 x109/L, Polynucléaire
neutrophile = 75 %)
• Echographie (Le foie est l'augmentation de la taille de
diamètre > 160mm avec les granulations de la
parenchymateux, de contour régulier, il y a présence une
collection liquidienne de 34mm x 47mm au segment VI.
Abcès du foie bactérienne
Conduit a tenir (Médical)
•PIV voie d’abord veineuse
•Antibiotique
•Antipyrétique
•Vitaminothérapie
Conduit a tenir
❑Traitement le J1-J5 (21-25/06/2022)
• PIV NSS 1000ml/j
• Metrolex 500mg x 3/jour PIV
• Ceftriazone 1g x 2/ jour IVL (test)
• Paracétamol 1000mg x3 /jour ( condition si T>38 °C) PO
• Multivitamine 1 x2 /jour PO
Evolution (22-25/06/2022)
• Evolution J2 (22/06/2022)
• Etat stationnaire, T= 38.3°C, Douleur abdominal (HCD)
• Evolution J3 (23/06/2022)
• Etat stationnaire, T= 38.5°C, Douleur abdominal (HCD)
• Evolution J4 (24/06/2022)
• Etat conservé, T= 36.7°C, Douleur abdominal (HCD) minime
• Evolution J5 (25/06/2022)
• Etat conservé, T= 37.0°C, Douleur abdominal (HCD) minime
Evolution (26-27/06/2022)
• Evolution J6 (26/06/2022)
• Etat conservé, T= 37.0°C, Douleur abdominal (HCD)
minime
• Evolution J7 (27/06/2022)
• Etat conservé, T= 36.9°C, Douleur abdominal (HCD)
minime
Traitement (26-27/06/2022)
• PIV (Stop)
• Ceftriaxone 1g x 2 /jour IVL
• Metronidazol 500mg x 3/jour PO
• Multivitamine 1cp x 2 /jour PO
Evolution
• Evolution J8 (28/06/2022)
à 08:10am ❑Traitement :
• Etat bon • PIV (Stop)
• Pas de fièvre • Ciprofloxacine 500mg 1 x 2/j
• Pas de douleur • Metronidazol 500mg x 3/jour PO
abdominal • Multivitamine 1cp x 2 /jour PO
• Appétit normal
Exéat : 28/06/2022 à 10:00 et
Rendez-vous : 03/07/2022
Control Echographie (27/06/2022)
Control Labo
(27/06/2022)
Education
• អៃតការពេទពលអថ្នែាំ (៥នងង)
• តម្េវសារពេទ ស្រសា
• តម្ជក់បារពេទ ី
• អាហារពេទ (គ្តី សាច្់ អផ្ៃែឆ្វៃ
ិ )....
វ
• គ្ត អ់ម្ក ញតាម្ការពេទ ណ្តត់ជួអរពេទអស់គ្រូពេទ្យ
Littérateur
Les Abcès Hépatiques (Abcès du foie)

Plans
I. Définition
II. Epidémiologie
III. Anatomo-pathologie
IV. Etiologie
V. Diagnostique positif
VI.Diagnostique différentiel
VII.Pronostique
VIII.Traitement
I. Définition
• Abcès du foie est une collection suppurée
dans le parenchyme hépatique d‘origine
bactérienne ou amibiennes.
II. Epidémiologie
• Age moyen du diagnostique : 30-60 ans
• Sexe: H=F
• Terrain à risque : Diabète sucré , alcoolisme
chronique , immunodéprimée
• Zone d‘endémie : amibienne ( Pays Tropicaux)
III. Anatomo-pathologie
• Abcès : Pus + débris nécrotiques
• Unique ou Multiple
• De quelques millimètres à plusieurs centimètre
• Macro- abcès : Unique (50-70%) lobe droite
• Micro- abcès : multiple .
IV. Etiologie
1. Pyogènes:
• Aérobie Bacille gram négatifs : 40-60% (
Escherichia coli, Klebsiella , Pseudomonas..)
• Aérobie bacille gram positifs : 10-20% (
Streptocoques, Staphylocoques..)
• Anaéribie : 35%-45% ( Bacteroide fragilises…)
2. Amibiennes :
• Protozoaire ( Entamoba histolytica)
V. Diagnostique positif
1. Clinique :
• Symptôme généraux : fièvre (>39°C) , frissons
asthénie, anorexie, amaigrissement…soit ictère
• Symptôme locaux : Douleurs HCD
• Examen : Hépatomégalie douloureuse, douleur à
l‘ébranlement du foie
• Soit diarrhée séro-sanglant
V. Diagnostique positif (suite)
2. Para clinique :
• Biologique NFS ( Hyperleucocytose ) , CRP élevée
• Hémoculture , Sérologie de l‘amibiase
• Echographie : (Zone hypo- échogene)
• TDM abdominal: Image (zone hypodense )
• Ponction : échoguidée et antibiogramme pour
confirme le diagnostique .
VI. Diagnostique différentiel
• Abcès amibien ou bactérien
• Cholécystite
• Tumeur du foie
• Pneumonie basal
• Kyste biliaire.
VII. Pronostique
• Sans traitement : l'abcès augmente de volume ->
fusille -> Péritonite,…
• Sous traitement : Médical / Ponction /Chirurgical le
guérison est la règle et améliore quelque semaines.
• Mortalité : 0-14% ( Age , sévérité du sepsis).
VIII. Traitement
• Bactérienne: Antibiotique à large spectre selon de
taille < 4cm ( Voie IV pendant 1-2 semaines puis relais
par voie oral 4-6 semaines )
• Amibienne: Métronidazole 1.5g /jour pd 10-20 jour
• Ponction aspiration Echo-guidée de la collection de
taille < 5cm
• Chirurgical : si la taille > 5cm
• Traitement préventif : mesure d‘ hygiène et éducation
sanitaire.
Référence
1. Lowry P, Rollins NK. Pyogenic liver abscess complicating ingestion of sharp objects.
https://www.edimark.fr/Front/frontpost/getfiles/4296.pdf. Pediatr Infect Dis J 1993 ; 12 : 348. 8.Tsui
BC, Mossey J. Occult
2. Johannsen EC, Sifri CD, Madoff LC. Pyogenic liver abscesses.
https://www.clinicalmicrobiologyandinfection.com/article/S1198-743X(14)64099-4/pdf. Infect Dis
Clin North Am 2000; 14: 547–63.
3. https://www.powershow.com/viewfl/54fdf9-
ODUxN/LES_ABCES_DU_FOIE_powerpoint_ppt_presentation
សូមអរគុណ !
Secondary peritonitis cause
by perforated peptic ulcer:
Case report and
a literature review
Men Sokha, MD, MHP.

Chey Chumneas Referral Hospital of
Kandal Province.
8/23/2022 1
Out line:
I, Introduction.
II, Case report.
III, Literature review.
IV, Discussion.
V, Conclusion.
8/23/2022 2
I, Introduction: Objective.
➢ To understand signs and symptoms of

secondary peritonitis.
➢ To know steps to diagnosis.
➢ How to manage the patient.
8/23/2022 3
II, Case report:
1, Biography:
A male patient 78yolds, live at ChbaAmpov
PP. Come in hospital with a reason of general
abdominal pain for the last 3 day.
8/23/2022 4
II, Case report (con):
2, History:
The patient has been examine and treated at
one hospital with diagnosis appendicitis. After
diagnosis has confirmed, his family decided
transfer to chey chhumneas hospital on 25
May 2022 at 15H00.
8/23/2022 5
3, Ancient:
➢ Intermittent alcohol used and smoking.
➢ Used to got dyspepsia and intermittent pain

at epigastric for long times.
➢ Acute onset pain at right lower quadrant
and he has treated with unknown medical
drugs in the last 3day.
➢ Never got any surgical and never got
medical checkup for his chronic disease.
8/23/2022 6
4, Clinical examination:
➢ GCS: M+E+V=14/15.
➢ Cannot sleep in decubitus position (Lie on

bed with supine and knees bent).
➢ General acute abdominal pain, no

irradiation to back.
➢ BP 135/85mmHg, P100/mn, To38.5,
RR24/mn, SpO2 97%, 165cm, 57Kg.
8/23/2022 7
4, Clinical examination (con):
➢ Nausea no vomit and no diarrhea, no
lymph nodes in peripheral, no extremities
edematous and cyanosis.
➢ Mild of dehydration signs. Anemia signs
are not clear. Lungs clear, heart sound no
murmur.
➢ No signs of abdominal distension and not
clear bowel sound.
8/23/2022 8
4, Clinical examination (con):
➢ Severe general abdominal tenderness.
➢ Abdominal getting mild guarding and

rigidity.
➢ Difficult to confirm there is mass or not.

8/23/2022 9
5, Clinical balance:
➢ Intermittent alcohol used and smoking.
➢ Used to got dyspepsia and intermittent pain

at epigastric for long times.
➢ Never got any surgical and never got
medical checkup for his chronic disease.
8/23/2022 10
5, Clinical balance (con):
➢ Acute onset pain at right lower quadrant and
he has treated with unknown medical drugs
in the last 3day.
➢ Nausea no vomit, no diarrhea, no lymph
nodes in peripheral, no extremities
edematous.
➢ BP 135/85mmHg, Pulse 100/mn, To38.5,
RR24/mn, SpO2 97%, 165cm, 57kg.
8/23/2022 11
➢ GCS: M+E+V =14/15.
➢ Generalized acute abdominal pain, no

irradiation to back.
➢ Mild of dehydration signs.
➢ Anemia signs is not clear.
8/23/2022 12
➢ Cannot sleep in decubitus position.
➢ No signs of abdomen distention. Weak of

bowel sound.
➢ Severe general abdominal tenderness.
➢ Abdominal getting mild guarding and
rigidity.
8/23/2022 13
➢ And difficulty to confirm there is mass or
not.
➢ Lungs clear, heart sound no murmur.
Suspect: Generalized peritonitis probably due
to appendicitis or perforated the hollow
organs.
8/23/2022 14
6, Different diagnosis:
➢ Appendicitis gangrenous.
➢ Hollow organs perforated.

➢ Acute pancreatitis.
➢ Acute cholecystitis.
8/23/2022 15
7, Laboratory investigations in urgent :
➢ CBC, blood group, CRP, PT, Creatinin,
Transaminase, Amylasemia, Glysemia,
Ionogram, HIV, ECG.
➢ General abd ultrasound.
➢ Thoracic x-rays, and plain abd x-rays.
➢ Abdomen CT scans if possible.
8/23/2022 16
8, Results of laboratory :
➢ WBC 16.1x109/L with Neutrophils 81, 5%,
RBC 10.3x109/L, Hb10.3g/dL, CRP
96mg(N<6mg),PT87%,Creatinin 1.0mg/dL,
SGOT50UI/L, SGPT45UI/L, Amylasemia
86mg/dL, Glysemia 80mg/dL, Calcemia
86mg/L , Na+ 133mmol/L, KCl
3.5mmol/dL, HIV(-).
8/23/2022 17
➢ ECG is in normal status.
➢ Ultrasound: Appendix hypertrophy 11mm in

transversal diameter, no liquid in Douglas
pouch.
➢ X-rays: Lungs in normal status and not
found free sub diaphragmatic air.
8/23/2022 18
8/23/2022 19
8/23/2022 20
9, Diagnosis before OP:
Generalized peritonitis probably due to
gangrenous appendicitis.
8/23/2022 21
10, management:
➢ Prepare for urgent OP.
➢ Liquid balance.
➢ Antibiotic prophylaxis.
➢ Pain management.
➢ GT and UT.
8/23/2022 22
11, OP:
➢ Skin incision at midline vertical.
➢ Abd cavity has got moderated volume (app

200ml) of gross purulent turbid fluid with
debris of food, milk color without fetid
smelled was aspirated from Douglas pouch.
➢ Appendix in normal site and normal
anatomy macroscopic.
8/23/2022 23
11, OP:
➢ Small intestinal tract was extended and not
found any lesion.
➢ Found one hole perforated at face anterior
of antrial region of stomach with diameter
approximately 3mm in middle of ulceration
region (app.1cm in diameter).
➢ Other organs are in normal macroscopic.
8/23/2022 24
11, OP:
➢ Biopsy in place, sutures the perforated site
associated with great omentum, lavage and
dry abd cavity clearly.
➢ Drainage at sites of sub hepatic space and
Douglas.
➢ Close wound. And blood lose app 10ml.
8/23/2022 25
11, OP:
Post OP diagnostic: General peritonitis cause
by perforated peptic ulcer.
8/23/2022 26
11, OP:
8/23/2022 27
12, Treatments post OP:
In fist 2 day:
➢ Continue liquid balance and nutrition.
➢ PPI.
➢ Antibiotic association.
➢ Early activity.
8/23/2022 28
12, Treatments post OP:
After day 3:
➢ Eating with good nutrient.
➢ Continue PPI and antibiotic associated.
➢ Wound take care.
➢ Hospital discharge on day 8.
8/23/2022 29
13, Advice after hospital discharge:
➢ Good nutrient.
➢ Continue PPI in 2 months and antibiotics at

least 2 weeks.
➢ No alcohol and tobacco used.
➢ Control by F.O.G.D.
8/23/2022 30
III, Literature review of peritonitis:
➢ Peritonitis is an inflammation of the
peritoneum.
➢ And peritonitis is usually caused by

infection from bacteria or fungi.
WedMD.
8/23/2022 31
1, Primary peritonitis1-3:
➢ Peritonitis develops as a complication of
liver disease, such as cirrhosis, or of
kidney disease.
➢ It is present in 10-25% of these patients on
hospital admission and accounts for as
many as 30% of all infection in cirrhotic
patient.
8/23/2022 32
1, Primary peritonitis1-3:
➢ The diagnosis of tuberculous peritonitis is
made by laparoscopy, with characteristic
findings of a thickened peritoneum with
military yellow-white tubercles.
➢ In most cases, diagnosis can base on the
gross findings, supplemented by results of
laparoscopic peritoneal biopsy.
8/23/2022 33
2, Secondary peritonitis4,5:
➢ Secondary bacterial peritonitis is defined
as peritoneal infection cause by perforated
of a hollow viscus or transmural necrosis
of the gastrointestinal tract.
8/23/2022 34
2, Secondary peritonitis4,5:
➢ Excluding trauma, the common causes of
generalized peritonitis include a perforated
appendix, perforated duodenal ulcer,
perforated sigmoid colon (caused by
diverticulitis, volvulus, or cancer)6-9,
strangulation obstruction of the small
bowel, and postoperative peritonitis cause
by anastomotic disruption.
8/23/2022 35
III, Literature review: signs and symptoms.
➢ Pain: is often steady, severe, and
aggravated by movement. The patient is
frequently lying still in bed, either in the
fetal position or supine with knees bent and
head elevated
➢ Anorexia and nausea are often
accompanying symptoms.
➢ Most patients are in acute distress.
8/23/2022 American college of Surgeons Book, 2013. 36
➢ Body temperature is usually higher than
38oC, but in cases of severe septic shock,
the patient may be hypothermic.
➢ Patient in septic shock may manifest high

cardiac output and reduced peripheral
resistance.
8/23/2022 37
➢ Tachycardia and diminished pulse volume,
indicative of hypovolemic, are common.
➢ Abdominal tenderness (diffuse) is the

hallmarked of peritonitis.
➢ Leukocytosis.
8/23/2022 38
➢ Plain abdominal x-rays may show evidence
of air fluid levels, and free fluid in
peritoneal cavity.
➢ Free air is evident in 80% of cases of
perforated duodenal ulcer but less
frequently after perforation of appendix, the
small bowel, or the sigmoid colon.
8/23/2022 39
➢ Ultrasonography is useful in equivocal
cases. The ability of ultrasonography to
detect less than 100ml of fluid in peritoneal
cavity may support the diagnosis of
peritonitis.
➢ CT scan provided the diagnosis in 95% of
cases.
8/23/2022 40
III, Literature review: anatomy.
th
8/23/2022 Source: internet . Mayo clinic Family Health Book, 5 Edition. 41
III, Literature review: management.
➢ With secondary peritonitis for operation
are fluid resuscitation.
➢ The initiation of antibiotic therapy.
8/23/2022 42
IV, Discussions:
➢ Generalized peritonitis need to be clear
etiology. The mortality rate rises up from
normal appearance 6% to 60% in case
sepsis4.
➢ For some RH need more equipment.
➢ Because of human resource App 1/3 among
peritonitis in our hospital were transfers to
national hospital.
8/23/2022 43
V, Conclusions:
➢ In general peritonitis can be developing to
septic shock.
➢ Diagnosis and treatment need to be as fast as
possible.
➢ Early diagnostic and right management can
save more people life.
➢ Treatment are differences between peptic
ulcer cause by H.pylori and malignancy
peptic ulcer. 8/23/2022 44
Referents:
1. Facciorusso A, Antonino M, Orsitto E, Sacco R. Primary and secondary prophylaxis of spontaneous bacterial
peritonitis: current state of the art. Expert Rev Gastroenterol Hepatol. 2019;13(8):751-759.
2. Farkas L, Lazáry G, Köves I, Csákváry V, Rónaky R, Nagy T. [Primary peritonitis in an adolescent boy]. Orv
Hetil. 2020;161(23):977-979.
3. Tolmáči B, Klein J, Žuffa P, Řehulková A. Primary pneumococcal peritonitis with a fulminant course. Vnitr
Lek. 2021;67(E-2):34-37.
4. Doklestić SK, Bajec DD, Djukić RV, et al. Secondary peritonitis - evaluation of 204 cases and literature
review. J Med Life. 2014;7(2):132-138.
5. Ross JT, Matthay MA, Harris HW. Secondary peritonitis: principles of diagnosis and intervention. Bmj.
2018;18(361).
6. Ogata K, Takamori H, Umezaki N, et al. Gastrointestinal perforation during regorafenib administration in a
case with hepatic metastases of colon cancer. J Chemother. 2016;20:1-3.
7. Abramyan S, Almadani MW, Sirsi S, Xiao PQ, Asarian AP. Perforation of appendiceal adenocarcinoma ex
goblet cell carcinoid: a rare case. J Surg Case Rep. 2018;19(9).
8. Kim IY. Minimally Invasive Interval Appendectomy for Perforated Appendicitis With a Periappendiceal
Abscess. Ann Coloproctol. 2016;32(3):88-89.
9. Turel O, Mirapoglu SL, Yuksel M, Ceylan A, Gultepe BS. Perforated appendicitis in children: Antimicrobial
susceptibility and antimicrobial stewardship. J Glob Antimicrob Resist. 2018;27(18):30188-30187.
10. Heemken R, Gandawidjaja L, Hau T. Peritonitis: pathophysiology and local defense mechanisms.
Hepatogastroenterology. 1997;44(16):927-936.
8/23/2022 45
THANK YOU!
8/23/2022 46
Parler par: Dr HUON BORA
Leuk Dek Referal Hospital
1
Objective
I. Etude sur le case Clinique
II. Evolution et Surveillance
III. Leur prise en charge
IV. Littérature
Case clinique
 LN âge de 55ans M,venant de Prek Tonleab
commun Leuk dek district, province de Kandal.
Il est entrée pour toux chronique avec strié du
sang , pert du poid.
3
Case clinique
 La maladie a remonté depuis un mois se

caractérisé par toux chronique avec strié du
sang s’accompagne de fièvre nocturne et pert
du poid Il a été traité par médicament de type
inconnue à domicile mais sans amélioration, 3
jours après les symptômes sont agravé. Ainsi
ses famille décidé le prendre pour traitement à
Leuk dek referral hôspital. C’est le motif
d’entré le 14/12/2021 9h:00.
4
Case clinique
+ATCD: Tabac(+) 30ans
+Signe vitaux:
-TA: 123/81 mmHg
-Pouls:99/min
-T:37.5oc
-RR: 20 /min
-SpO2: 96%
-Poids: 55kg
5
Case clinique
+Examen clinique
 EG: assez altéré
 Conscience: conservé
 T&C: assez pâleur
 Fièvre
 Toux
 Appetite(-)
 Asthénie intense
6
Case clinique
+Examen clinique
 Cage thoracique symétrique
 Dyspné minime
 Toux avec sang rouge aérée =10ml /24h
 MV et VV normal
 Râle crépitant bilatérale
 Autres appareilles sont normaux
7
Case clinique
+Para clinique
-GB: 8200/mm3
-Hb: 12.9g/dl
-Pt: 265/mm3
-Urée: 36mg/dl
-Créatinine: 1.2 mg/dl
8
Case clinique
+Para clinique
-CRP: positive
-ASAT: 29u/l
-ALAT:34u/l
-Groupage Sangine : B Rh+
9
Case clinique
 Radiographie pulmonaire:
10
Prise en charge
Traitement
 PIV NSS 1000ml
 Tranex Acide 500mg 1A X 2 (IVL)
 Cimétidine 300mg 1A X 2 (IM)
 Paracétamol 1g 1Fl X 3 (PIV)
 Vitamine B complet 1A (IM)
11
Prise en charge
 Gene X-pert (+)
le 15/12/2021
 RHZE 4 c (PO)
 Cimétidine 300mg 1A X 2 (IM)
 Paracétamol 500mg 1cX3 (PO)
 Vitamine B6 1 c (PO)
12
prise en charge
 Survaillance de
traitement par DOT .
 Hémoptysie diminué
 Hémodynamique stable
 Le 17 /12/2021
 Survallance :
function hépatique et rénal
 Exéat le 17/12/2021
13
prise en charge
 le 14/01/2022 à controlé
 Radiographie
 Avec hémoptysie (-)
 Apès Traitement Anti TB
un mois
Reference: Clinical practice guidelines for médicine 2013

14
PLAN
I. Définition
II.Epidémiologie
III.Etiologie
IV.Manifestation clinic
V.Para clinique
VI.Diagnostic
VII.Diagnostic différentiel
VIII.Traitement
15
I Définition
 L’hemoptysie correspond á une expectoration
de sang rouge vif, aéré,spumeus provenant des
voies respiratoires sous-glottique suite á une
toux.
16
II. Epidémiologie
Suivant l’étude épidémiologique du clinical
practice guideline for medicin nationale en
2013 les hémoptysie ont :
 5% hospitalisées en pneumologie
 1% d`hémoptysie grave
17
III. Etiologie
1. causes hémoptysie de plus frequent
 Tuberculose active (BK+)
 Tuberculose ancienne ou séquelaire
 Rechute TB
 Aspergillome
 Dilatation des bronches
 Cancer bronchique
18
III. Etiologie
2. Cause hémoptysie possible ou rare
• Infectieuse: bronchite aiguë , pneumopathie
á pneumocoque , aspergillose
• Vasculaire : hypertension veineuse
pulmonaire, embolie pulmonaire ,
• Hémorragie intra-alvéolaire:
19
IV. Manifestation clinic
 L’hemoptysie de moyenne abondance est la
plus frequent et la peut survenir suite à un
effort ou une poussée hypertensive. Elle peut
être précédée de prodromes comme une
sensation de mal être , une angoisse, une
sensation d’oppression voire même de la fièvre
 Initialement ,peut être décrit un picotement
laryngé, une chaleur retro-sternale ou une
saveur métallique dans la bouche .
20
IV. Manifestation clinic
 L’hemoptysie correspond á une expectoration
de sang rouge vif, aéré,spumeus provenant des
voies respiratoires sous-glottique
 Puis servient l’hémoptysie accompagnée de
une pâleur , tachycardie
 Cet épisode pert être unique ou répétitif puis
est suivi de chrachat de sang de plus en plus
foncé noirâtres les jours suivants correspondant
à la queue de l’hémoptysie.
21
V. Para clinique
a) Examen laboratoire :
NFS, plaquette , hémostase , groupage ,
rhésus
b) Rx thoracique
c) TDM tharacique
d) Bronchoscopie
e) Examen du chrachat ou Gene-Xpert
22
V. Para clinique
1. Radiographie thoracique de face ou profil
✓Les principales anormalies rencontrée :
• Opacité ronde à limites déchiquetée
• Opacité excavée
• Image de caverne
• Image en rosette dans le cadre de DDB
• Image hydro-aréique
• Condensation parenchymateuse
• Atélectasie 23
Radiographie thoracique de face
24
V. Para clinique
2. LA TDM THORACIQUE
 Permet une meilleure description des anormalie

observes au Rx thorax et la découverte
anomalie infra-radiologiques.
 Avec injection du produit de contrase ,elle
permet identification des anomalie vasculaires
,anévrysmes, faux anévrysme et malformation
arterio-veineuses
25
LA TDM THORACIQUE
26
3. Bronchoscopie
 Elle confirme parfois le diagnostic en
objectivant le saignement
 Précise origine du saignement
 Elle permet parfois le realization de hémostase
locale
27
VI. Diagnostic
 Appréciation du retentissement respiratoire et
circulatoire :(dédresse respiratoire , état de
choc ) par mesure des constants
hémodynamique ( FR, FC, TA, SpO2 )
 Préciser l’abondance :
✓<50ml/24H (strié de sang ou<1/2verre)=faible
abondance
✓50-500ml/24h = moyenne abondance
✓500ml/h = grande abondance
28
VII Diagnostic différentiel
 Épistaxie dégluti: intérêt d’un examen ORL
 L’hématémèse : qui est le rejet du sang
gastrique noirâtre mêlé à des debris
alimentaires lors d’un effort de vimissement
 Les gingivorragies: sang provenant de la
gencive intérêt d’un examenn stomatologique
29
VIII. Traitement
Les objective :
 Arrête de saignement et éviter récidive
 Latérisation saignement responsable
l’hémoptysie et researche la cause
30
VIII. Traitement
31
References
 Clinical practice guidelines for medicine 2013
 Cambodia NTP, Technical guideline on
Tuberculosis control. 2nd ed .2016
 Cambodia MoH, សសៀវសៅមគ្គុតទសក៍គ្លីនិកថ្នាក់ជាតិសម្រាប់ថែទាំ
ព្យាបាល ជាំងឺរសបង-សេដស៍, 2013
32
Merci pour vôtre attention!
33

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មន្ទរី ពេទ្យបង្អែក ជ័ យជំន្ះ

➢WHO Dengue fever classification

➢The following must all be present:

➢ All the four criteria for DHF must be present, plus

• Unusual dengue with rare occurrence

➢In Critical phase, start amount

➢Vital signs and peripheral ➢Warning signs

-His brother just resolved from DF last week.

• Growth and Development : Normal by age

• GA: look sick and drowsiness

• RS : Low air entry on right lung base,

- WBC: 10.7 (4-10) - Glycermia : 94 (79-140)

Impression: DSS response with IVF

Impression: DHF in convalescence

Impression: DHF in convalescence

1. National Guideline for Clinical Management of Dengue 2021.

➢ In Epidemic countries, patients who have high fever without

•Le patient âgé de 34 ans sexe masculine ,

Donc je pense probablement :

• HBs-Ag …………………………: Réaction négative

Les Abcès Hépatiques (Abcès du foie)

Men Sokha, MD, MHP.

➢ To understand signs and symptoms of

➢ To know steps to diagnosis.

➢ How to manage the patient.

➢ Used to got dyspepsia and intermittent pain

➢ Cannot sleep in decubitus position (Lie on

➢ General acute abdominal pain, no

➢ Abdominal getting mild guarding and

➢ Difficult to confirm there is mass or not.

➢ Used to got dyspepsia and intermittent pain

➢ Generalized acute abdominal pain, no

➢ No signs of abdomen distention. Weak of

➢ Hollow organs perforated.

➢ Ultrasound: Appendix hypertrophy 11mm in

➢ Abd cavity has got moderated volume (app

➢ Continue PPI in 2 months and antibiotics at

➢ And peritonitis is usually caused by

➢ Patient in septic shock may manifest high

➢ Abdominal tenderness (diffuse) is the

➢ The initiation of antibiotic therapy.

 La maladie a remonté depuis un mois se

Reference: Clinical practice guidelines for médicine 2013

 Permet une meilleure description des anormalie

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