WTP3.13 Matted Bowel and Migrating Fistulas: Reflections on Navigating the Complexities of Perforation Peritonitis and Improving Patient Outcomes

Aims To highlight the multidisciplinary coordination required for managing perforation peritonitis in a young patient with atypical mycobacteria, HIV, and haemophagocytic lymphohistiocytosis (HLH). Methods A patient in their 20s presented in septic shock at midnight requiring inotropic support, with a one-year history of weight loss. Examination revealed a cachectic individual with a grossly distended, tender abdomen. CT images revealed free fluid, locules of free air and clustered small bowel loops concentrated around the mid abdomen. Resuscitation followed the sepsis protocol, and an emergency laparotomy was performed. Intraoperatively, densely adherent matted, dusky small bowel loops with purulent fluid and multiple white nodules (images) were observed throughout visceral and parietal peritoneal surfaces. A damage control approach included extensive peritoneal washout, biopsies and abdominal drains, avoiding bowel disturbance to prevent further damage. Results Cultures identified atypical mycobacteria and polymicrobial flora. Histology (images) showed granulomas (caseation with atypical mycobacteria) and testing revealed first-presentation HIV with a very low CD4 count and a high viral load. Postoperatively, the patient developed migrating enterocutaneous fistulas, managed through an intestinal failure protocol and anti-TB therapy. HLH delayed antiretroviral therapy, requiring sequential treatment for HLH, HIV, and tuberculosis. Despite the complexity, the patient recovered, transitioned to oral feeding, gained weight and resumed normal activities within a year. Conclusions This case highlights the value of damage control surgery, early biopsy and microbiology sampling in managing matted bowel. Multidisciplinary input and the sequential treatment were pivotal role in recovery. Insights can guide management of similar cases in resource-constrained, time-critical settings.