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Tube Feedings Formulas and Methods
Published in Michael M. Rothkopf, Jennifer C. Johnson, Optimizing Metabolic Status for the Hospitalized Patient, 2023
Michael M. Rothkopf, Jennifer C. Johnson
Underlying bowel diseases such as Crohn’s and ulcerative colitis may be present. Bowel ischemia due to mesenteric artery stenosis could be present. In addition, recovery from intestinal obstruction and/or surgery can be a cause of hospital diarrhea. Pancreatitis and the resulting pancreatic insufficiency may be another cause.
Treatment of Abdominal Sepsis
Published in Stephen M. Cohn, Alan Lisbon, Stephen Heard, 50 Landmark Papers, 2021
For ICU patients with sepsis and septic shock, the abdomen is a common source of infection, ranking second behind pulmonary sources [2, 3]. Although a variety of etiologies can cause intraabdominal infections, secondary peritonitis from bowel perforation and bowel ischemia/infarction together causes nearly 50% cases of abdominal sepsis [2]. Other causes include spontaneous bacterial peritonitis, Clostridium difficile colitis, intraabdominal abscess, hepatobiliary sources such as cholangitis, cholecystitis, and hepatic abscess, and infected necrotizing pancreatitis. As with other causes of sepsis and septic shock, time to appropriate resuscitation and appropriate empiric antibiotic therapy significantly alters the outcome. In large observational studies, each 30 minute delay in antibiotic therapy for patients with abdominal sepsis and shock is associated with a 12% increase in mortality and adequate empiric antibiotic therapy independently associated with survival (odds ratio ∼9) [2, 3].
Complications of open repair of splanchnic aneurysms
Published in Sachinder Singh Hans, Mark F. Conrad, Vascular and Endovascular Complications, 2021
Bjoern D. Suckow, David H. Stone
Complications of open SMA aneurysm repair relate to the location of the aneurysm along the SMA axis and the extent of repair required. Bowel ischemia and need for bowel resection is related to incident presentation (occlusion or mycosis) and the ability to preserve or re-establish bowel perfusion. Given the high likelihood of a mycotic etiology and/or bowel ischemia requiring resection, we advocate against the use of prosthetic bypass/interposition graft or prosthetic patch if aneurysmorrhaphy is performed. If the underlying etiology is from intravenous drug abuse or bacterial endocarditis, recurrent SMA aneurysms may develop unless the underlying condition is addressed. Patients with vasculitis may also present with multifocal SMA aneurysms (Figure 22.4) or may develop metachronous de novo aneurysms at a later time. Therefore, surveillance imaging of these patients is warranted.29,31,33 More routine surgical complications such as postoperative ileus, adhesion-related bowel obstruction, bowel stricture from ischemia, pancreatitis from dissection around the proximal SMA, and myocardial infarction also apply and should be considered during the postoperative period following open SMA aneurysm repair.
Advancements in the pharmacological management of sepsis in the elderly
Published in Expert Opinion on Pharmacotherapy, 2023
Christos Psarrakis, Evangelos J. Giamarellos-Bourboulis
Another important therapeutic modality for the elderly is proper caloric diet. Current guidelines suggest that enteral nutrition could be initiated when hemodynamic stability has been achieved, after prompt fluid resuscitation. In the multicenter, open-label NUTRIREA-2 RCT, 2410 patients (mean age 66 years) with septic shock under MV were randomized to receive either parenteral or enteral nutrition via a nasogastric tube within the first 24 hours after start of MV. No difference in 28-day all-cause mortality was found between the two treatment groups (35% vs 37% respectively, p = 0.33), but an increased incidence of gastrointestinal adverse events was noticed for patients allocated to enteral nutrition. More specifically, higher incidence of vomiting (20% vs 34%, HR: 1.89, p < 0.0001), diarrhea (33% vs 36%, HR 1.20, p = 0.009), bowel ischemia (<1% vs 2%, HR: 3.84, p = 0.007) and acute colonic pseudo-obstruction (<1% vs 1%, HR: 3.7, p = 0.04) were recorded [22].
Gastric bleeding in giant cell arteritis
Published in Baylor University Medical Center Proceedings, 2021
Austin Childress, Thomas J. Kwarcinski, Joseph Scott H. Bittle, Clayton Trimmer
In this case, there was extravasation from an irregular left gastric artery, concerning for vasculitis. Visceral arteriopathy is an atypical manifestation of GCA and abdominal symptoms may not manifest due to the extensive collateral network of vessels maintaining visceral perfusion in the abdomen.4 Indeed, many of the patients in the described reports presented only after acute abdominal events such as bowel ischemia or infarction. In this patient with angiographic evidence of vasculitis, arterial extravasation, hemoperitoneum, and a history of GCA, extracranial involvement of the celiac artery is a strong consideration. It should be noted that the patient had extensive atherosclerosis; thus, GCA superimposed on an already weakened vessel wall is a possibility that could have led to the hemoperitoneum/extravasation.
Imaging in pancreatitis: current status and recent advances
Published in Expert Opinion on Orphan Drugs, 2018
Itegbemie Obaitan, Umar Hayat, Hiba Hashmi, Guru Trikudanathan
Vascular complications are common in moderate severe and severe AP and include splanchnic vein thrombosis, arterial pseudoaneurysm and hemorrhage secondary to erosion of arteries, veins and capillaries either spontaneously from pancreatic enzymes or following surgical, percutaneous and endoscopic interventions. Splanchnic vein thrombosis may frequently involve the splenic vein followed by portal vein, and superior mesenteric vein either alone or in combination Irrespective of the etiology, splanchnic vein thrombosis is known to occur in up to 24% of patients with acute pancreatitis [18]. Although pathogenesis is unclear, the systemic inflammatory cascade associated with AP together with action of proteolytic enzymes weakens vessel wall and precipitates stasis of blood flow [19,20]. Acute portomesentric venous thrombosis appears as persistent, well-defined intraluminal filling defects with central low attenuation which may be surrounded by well-defined, rim-enhancing venous walls. In case of chronic thrombosis, collaterals can be seen in addition as well. Acute thromboses are accompanied by bowel ischemia which presents as alternating intramural areas of high and low attenuation resulting from submucosal edema or hemorrhage [18]. Small bowel and colonic ischemia with subsequent necrosis and perforation are rare but dreaded complications of severe AP. It is crucial to recognize the CT findings of bowel necrosis including presence of pneumatosis intestinalis, gas in the portomesentric veins and diminished or absent bowel wall enhancement as it carries substantial mortality if not managed expectantly.