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Hepatobiliary and pancreatic emergencies
Published in Alexander Trevatt, Richard Boulton, Daren Francis, Nishanthan Mahesan, Take Charge! General Surgery and Urology, 2020
Routine bloods should be ordered including: FBC (full blood count), U&E (urea and electrolytes), LFTs (liver function tests), clotting screen, group and save, ABG (arterial blood gas)/VBG (venous blood gas). However, they are often unhelpful as critically ill patients normally have a number of coexisting pathologies, which will also lead to deranged blood results. Blood cultures should be taken if febrile.Erect chest X-ray To rule out a chest infection.To look for air under the diaphragm.Abdominal X-ray To look for pneumobilia (air in the bile duct, signifying sphincter of Oddi incompetence, biliary-enteric fistula or infection).To look for biliary stents or clips from a previous cholecystectomy.
Intestinal obstruction
Published in Professor Sir Norman Williams, Professor P. Ronan O’Connell, Professor Andrew W. McCaskie, Bailey & Love's Short Practice of Surgery, 2018
Professor Sir Norman Williams, Professor P. Ronan O’Connell, Professor Andrew W. McCaskie
This type of obstruction tends to occur in the elderly secondary to erosion of a large gallstone directly through the gall bladder into the duodenum. Classically, there is impaction about 60 cm proximal to the ileocaecal valve. The patient may have recurrent attacks as the obstruction is frequently incomplete or relapsing as a result of a ball-valve effect. The characteristic radiological sign of gallstone ileus is Rigler’s triad, comprising: small bowel obstruction, pneumobilia and an atypical mineral shadow on radiographs of the abdomen. The presence of two of these radiological signs has been considered pathognomic of gallstone ileus and is encountered in 40-50% of the cases (note than pneumobilia is common following endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy). At laparotomy, the stone is milked proximally away from the site of impaction. It may be possible to crush the stone within the bowel lumen; if not, the intestine is opened at this point and the gallstone removed. If the gallstone is faceted, a careful check for other enteric stones should be made. The region of the gall bladder should not be explored.
Test Paper 5
Published in Teck Yew Chin, Susan Cheng Shelmerdine, Akash Ganguly, Chinedum Anosike, Get Through, 2017
Teck Yew Chin, Susan Cheng Shelmerdine, Akash Ganguly, Chinedum Anosike
A 65 year old known diabetic woman is acutely unwell and presents with increasing epigastric tenderness. She is referred by the surgeons for an urgent contrast enhanced CT of the abdomen. The CT shows features consistent with emphysematous gastritis. All of the following are expected CT findings, except: Air in the stomach wallPneumoperitoneumPneumobiliaPortal venous gasIrregular gastric mucosal fold thickening
Efficacy of endoscopic ultrasound after removal of common bile duct stone
Published in Scandinavian Journal of Gastroenterology, 2019
Yeon-Ji Kim, Woo Chul Chung, Ik Hyun Jo, Jaeyoung Kim, Seonhoo Kim
Clinical and laboratory data related to the recurrence of CBD stones were retrospectively searched from patient files. Baseline characteristics such as age, sex, and body mass index were examined. The presence of gallbladder stone, prior cholecystectomy history, size of the largest stone, type of stones, number of ERCP sessions, presence of periampullary diverticulum, CBD diameter, CBD angulation, mechanical lithotripsy use, EPLBD use, and presence of pneumobilia were recorded. All data were extracted from the baseline ERCP in all patients. Distal CBD angulation observed on cholangiography was defined as the first angulation from the ampullary orifice along the course of the CBD. The diameters (maximum transverse diameter) of the stone and CBD were measured after correction for magnification using the known diameter of the endoscope on cholangiogram [11].
Rare cause of gastric outlet obstruction
Published in Journal of Community Hospital Internal Medicine Perspectives, 2018
Similarly, the CT scan in Figure 1, shows the stone in the duodenal lumen as shown in the attached image (pointed with an arrow.) Regarding the pathogenesis of Bouveret’s syndrome, we mentioned in our case report that it is caused by the cholecysto-enteric fistula. We agree with your description of dividing the passage of the stone from either cholecysto-gastric, cholecysto-duodenal and choledocho-duodenal. We were unable to visualize the fistula because of the degree of ulceration that was seen on the initial EGD.The diagnostic approach for our patient was multi modal. The patient underwent CT scan of the abdomen, ERCP, EGD, EUS and PET CT for the diagnostic process. EGD was one modality but initial diagnostic workup was started with imaging. Initial CT scan revealed marked distention of stomach, pneumobilia and poor gall bladder visualization. This was followed by EGD and EUS. PET CT was performed subsequently as suspicion for malignancy was high based on the initial EGD.
Images in surgery – gallstone ileus
Published in Acta Chirurgica Belgica, 2018
Laurie Stiennon, Olivier Detry
Gallstone ileus accounts for less than 1% of small-bowel obstructions and is more frequent in elderly women [1–4]. GI is frequently preceded by an acute cholecystitis. The inflammation of the gallbladder and surrounding structures leads to adhesion formation and erosion through the gallbladder. These changes can lead to a fistula with the neighbouring structures and with further gallstone passage. The fistula between gallbladder and the duodenum is the most frequent due to their proximity but it can also occur with the stomach, small bowel, and transverse colon [2]. The clinical presentation is usually non-specific and can be misdiagnosed due to its rarity. The patients appear often with intermittent symptoms of nausea, vomiting, pain, and abdominal distension [4]. The modern gold standard diagnostic tool is the CT scan that shows pneumobilia, intestinal obstruction, and an aberrantly located gallstone [3].