Pancreatic Pseudocyst
Stephen M. Cohn, Peter Rhee in 50 Landmark Papers, 2019
Patients with a possible PS who have no prior history of acute/chronic pancreatitis episodes or symptoms (or trauma) should prompt consideration of an alternative diagnosis of cystic neoplasm of the pancreas. However, up to 15% of PS have no clearly identified antecedent pancreatitis episode or trauma and a significant percent of pancreatic cystic neoplasms may initially present as an episode of acute pancreatitis. There are essentially no symptoms or exam findings that are specific to PS and the majority of patients will have either minimal or no symptoms. If symptoms are present, they most commonly will feature vague upper abdominal and/or back pain, bloating, early satiety or pain shortly after meals, or less commonly, symptoms of gastric outlet obstruction. Elevated serum amylase levels are seen in approximately 50% of patients with PS and are often mistakenly attributed to “recurrent pancreatitis.”
SBA Answers and Explanations
Vivian A. Elwell, Jonathan M. Fishman, Rajat Chowdhury in SBAs for the MRCS Part A, 2018
Meconium ileus can cause neonatal intestinal obstruction and typically presents in patients with cystic fibrosis (CF) in 10 per cent of cases, where the deficiency of pancreatic enzymes causes the meconium to be thick and viscous. It presents within the first few hours of life with absolute constipation, bile-stained vomiting, and abdominal distension. Meconium is normally passed within the first 24 hours but this fails to occur. Abdominal X-ray (AXR) may display a mottled appearance from the lipid droplets within the meconium. It may be difficult to differentiate from Hirschsprung disease but this typically has multiple air fluid levels on erect AXR. Treatment is with gastrografin enema, provided that there is no evidence of perforation. Gastric outlet obstruction usually presents with non-bilious vomiting.
Complications of Gastric Surgery
Stephen M. Cohn, Matthew O. Dolich in Complications in Surgery and Trauma, 2014
For patients who have previously undergone pyloroplasty, pyloric reconstruction is a viable option. The pyloroplasty is opened, the sphincter muscle is reapproximated, and the incision is closed longitudinally. Reported success rates vary widely.11–13 Conversion of a Billroth II anastomosis to a Billroth I anastomosis reestablishes the gastroduodenal flow of food, is associated with low rates of complication, and improves the symptoms of approximately 75% of patients. Many types of jejunal interpositions have been described. The most successful has been the 10 cm antiperistaltic jejunal segment, which may be interposed between the stomach and the duodenum, in the efferent limb of a gastrojejunostomy, or in a Roux-en-Y limb. Several authors report good results with this procedure, but others report a serious risk of gastric outlet obstruction.14 For patients with a previous Billroth I or II anastomosis, conversion to a Roux-en-Y gastrojejunostomy has provided the most consistent results.14–16
Combined endovascular and surgical treatment of a giant celiac artery aneurysm with consequent gastric outlet obstruction: a case report and literature review
Published in Acta Chirurgica Belgica, 2023
Nick Smet, Thijs Buimer, Tim Van Meel
Only a few cases in the literature were found of visceral artery aneurysms where gastric outlet obstruction or jaundice was the presenting symptom [16,23]. Tipaldi et al. reported a high technical and clinical success rate of 91% of endovascular treated GVAAs. However, only one out of 11 patients presented with obstructive symptoms (jaundice) due to a hepatic aneurysm of 5.6 cm [16]. As proved by this case, it is of paramount importance to exclude all inflow and outflow vessels to diminish the risk of reperfusion (the double blockage technique) and prevent rupture of the aneurysm. Furthermore, this case emphasizes the benefit of an endovascular first approach. The need for subsequent treatment of the gastric outlet obstruction remains. In this case, no extensive dissection or visceral rotation for arterial control is needed to perform an aneurysmectomy due to the previous embolization of feeding arteries. Unfortunately, our patient required several abdominal interventions to resolve the delayed gastric emptying. The reason for persisting gastroparesis remains unclear, but a possible hypothesis could be the chronic compression/irritation of nerve plexuses around the stomach and duodenum by this giant CAA.
Bouveret’s Syndrome: Sense and Sensitivity
Published in Journal of Community Hospital Internal Medicine Perspectives, 2018
John Ong, Carla Swift, Sharon Ong
Firstly, the endoscopic images provided in Figure 2 do not show a gallstone occluding the lumen of the duodenum but rather a yellowish-brown gallstone within a large ulcer with surrounding congealed blood. Similar to the endoscopic findings, the first CT scan did not demonstrate a gallstone occluding the gastric or duodenal lumen. In considering these results from both modalities, the diagnosis of Bouveret’s syndrome in this case hinges on circumstantial evidence and is open to debate. The definitive evidence that was presented; the results of the second CT scan and the laparotomy findings clearly demonstrated gallstones in the jejunum and ileum which favours the diagnosis of gallstone ileus rather than Bouveret’s syndrome. We acknowledge the images from the first endoscopy were suboptimal and it may well be that the authors have undisclosed clinical information that helped them reached their final conclusion. However, if based solely on the information that was presented, an alternative cause of the gastric outlet obstruction is also plausible, e.g., duodenal stenosis caused by inflammation around the large duodenal ulcer which is supported by the retention of congealed blood within the duodenum and the subsequent resolution of symptoms with intravenous proton pump inhibitors.
Symptomatic gastric involvement in a parastomal hernia: uncommon presentation
Published in Acta Chirurgica Belgica, 2020
Maaike Vierstraete, Dirk Van de Putte, Piet Pattyn
In patients presenting with obstructive symptoms, one should be aware of a possible gastric outlet obstruction because of its involvement in a PSH, although sporadic. Increased laxity of the gastric ligaments due to mechanical stress (expansion of the abdominal cavity or increased abdominal pressure) is thereby essential. Regarding our two cases and the limited experience in literature, mainly older females with colostomies are at risk and most of them need surgery. Surgery might thus be considered as the treatment of choice because conservative treatment mostly fails. Earlier surgery might perhaps reduce postoperative hospital stay and gastroparesis, but larger series are needed to confirm these findings.
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