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A junior SHO's experience on the surgical admission unit
Published in Tim French, Terry Wardle, The Problem-Based Learning Workbook, 2022
It is difficult to miss the diagnosis of generalised peritonitis, once you have seen a few cases. This man’s symptoms have come on rapidly and his observations confirm what his wife could see instantly – that he is very ill. Therefore, something has happened suddenly and the likely causes are: perforated peptic ulcer: the patient’s indigestion could indicate previous peptic ulcer diseasefaecal peritonitis: perhaps the patient’s ‘irritable bowel’ was really diverticular disease or even (sigmoid) colon canceracute pancreatitis: this can be alcohol induced (see p. 122)bowel infarction: in this patient this is an unlikely diagnosis, because there are no features to indicate either atherosclerosis or new-onset atrial fibrillation (leading to an arterial embolus). Usually extensive bowel infarction is either secondary to prolonged closed loop obstruction (discussed above), or to loss of blood supply to the infarcted segment of bowel.
Mesenteric Ischemia
Published in Stephen M. Cohn, Alan Lisbon, Stephen Heard, 50 Landmark Papers, 2021
The goal of intervention is focused on expeditious restoration of visceral perfusion (Ryer et al., 2012; Corcos et al., 2013). In patients with embolism, a midline laparotomy is performed and a Fogarty embolectomy catheter is passed proximally and distally and flow is restored. This approach also allows for assessment of bowel viability. In patients with mesenteric thrombosis, thrombectomy alone is unlikely to be effective or durable. Mesenteric bypass, classically considered the “gold-standard,” constructs a graft from the aorta or iliac artery to a site distal to the occlusion. It offers excellent relief and is remarkably durable, however, it can be prohibitive in patients in shock or those with extensive cardiovascular comorbidities (Johnston et al., 1995; Klempnauer et al., 1997; Björck et al., 2002; Cho et al., 2002; Roussel et al., 2015). Endovascular and hybrid approaches, typically by means of mechanical thrombectomy or angioplasty and stenting, may be as effective as traditional surgical approaches while eliminating the need for aortic cross clamping, minimizing physiologic insult (Milner et al., 2004; Wyers et al., 2007). If endovascular-only therapy is pursued, any evidence of clinical deterioration or peritonitis necessitates operative exploration (Clair and Beach, 2016). Poor-risk surgical candidates with extensive small bowel infarction may be best served by a palliative approach.
General Medical Emergencies
Published in Anthony FT Brown, Michael D Cadogan, Emergency Medicine, 2020
Anthony FT Brown, Michael D Cadogan
Look for unequal or absent pulses, a difference of blood pressure in the arms >20 mmHg, or the following complications of the dissection: Aortic incompetence, myocardial ischaemia and haemopericardium with pericardial rub or cardiac tamponade (see p. 10).Dyspnoea, pleural rub or effusion due to haemothorax.Agitation, altered consciousness, syncope, hemiplegia or paraplegia.Intestinal ischaemia or bowel infarction with abdominal pain and bloody diarrhoea.Oliguria and haematuria.
Gastrointestinal vaso-occlusive crisis in sickle cell disease
Published in Baylor University Medical Center Proceedings, 2022
Garima Gautam, Robert Harmon, Raymond Foley
Rarely observed, girdle syndrome is a clinical syndrome in which vaso-occlusion occurs in the lungs, liver, and mesentery with characteristic pain in a girdle-like distribution.4 Our patient presented with girdle syndrome which, although rare, progressed to bowel infarction. Abdominal pain in patients with SCD can represent a diagnostic challenge for clinicians. The disease can often result in generalized and diffuse pain, which can be exacerbated by adverse effects of therapies such as constipation from opioids or abdominal pain from deferasirox. The diagnosis of vaso-occlusive crisis–related gastrointestinal ischemia is based on the presentation of acute abdominal pain crisis, a constellation of clinical findings, a lack of an alternative unifying diagnosis, and the resolution of symptoms with supportive management in uncomplicated cases. In SCD patients with vaso-occlusive enteritis, abdominopelvic CT with intravenous contrast may reveal the target appearance of bowel wall thickening with mucosal hyperenhancement and submucosal edema.5,6 Interestingly, our patient’s CT of the abdomen revealed findings suggestive of enteritis and colitis.
Technical success and outcomes using a flexible bifurcated stent graft (AorfixTM) in abdominal aortic aneurysms: a systematic review
Published in Expert Review of Medical Devices, 2021
Aazeb Khan, Emily Khoo, Vivak Hansrani, Mohamed Banihani, Haisum Qayyum, George A. Antoniou, Bella Huasen
The majority of the complications listed in Table 3 occurred due to partial or complete coverage of a visceral aortic branch by the endograft, or limb occlusion. There were four reported cases of acute limb ischemia, requiring intervention, of which three were within 2 days of the primary procedure [12,13], and the fourth patient presented on day 14 post procedure due to endograft limb occlusion [16]. Internal iliac artery occlusion reported in 12 patients (planned in one only) had mild buttock claudication symptoms and required no intervention. One author reports an ipsilateral external iliac artery occlusion occurring due to damage from the delivery system [7]. There were two reported cases of bowel ischemia, one managed conservatively [13], and the other patient died due to bowel infarction found on laparotomy [12]. Out of the four patients reported to have renal impairment, only one required renal artery stenting [13], but none of them required any renal support.
Fetal hydrops – a review and a clinical approach to identifying the cause
Published in Expert Opinion on Orphan Drugs, 2020
Esther Dempsey, Tessa Homfray, John M Simpson, Steve Jeffery, Sahar Mansour, Pia Ostergaard
Gastrointestinal causes are included in most etiology reports of nonimmune fetal hydrops. However, they make up a small percentage of all cases and there are a limited number of case reports. Meconium peritonitis results from the rupture of the fetal bowel and the leak of meconium into the peritoneal space. The inflammation that ensues appears as calcifications on the fetal ultrasound and dilated bowel loops. It is seen more frequently in fetuses with cystic fibrosis although it is still a rare complication. Meconium peritonitis usually causes ascites, but this has been shown to cause a more severe presentation of hydrops [165]. Any cause of bowel infarction and resultant fluid loss into the peritoneal cavity (stenosis, atresia, volvulus, peritoneal bands, imperforate anus, intussusception) can cause edema as a result of the reduced vascular colloid osmotic pressure [9].