Two Centimeter D1–2 Anterior Perforation Presenting 24 Hours Later
Savio George Barreto, Shailesh V. Shrikhande in Dilemmas in Abdominal Surgery, 2020
Sudden onset of abdominal pain, tachycardia, and abdominal rigidity constitute the classic triad of a perforated peptic ulcer. The clinical manifestations evolve over three phases [1]. The first phase lasts for around two hours from the onset of perforation. The entry of acid into the peritoneal cavity results in chemical peritonitis which is initially localized to the upper abdomen. Thus, the pain starts in the epigastrium but soon becomes generalized. The release of vasoactive mediators due to peritoneal reaction results in tachycardia and cold extremities. The second phase begins around two hours from the onset and lasts till around 12 hours. Pain may become less severe initially as the acid gets diluted by the fluid released due to peritoneal reaction. However, pain is more generalized and becomes worse on any movement. The signs of peritonitis (tenderness, guarding, and rigidity) also become apparent. The third phase usually begins after 12 hours as the peritoneal inflammation progresses further. There is increasing abdominal distension as paralytic ileus sets in and fluid accumulates in the peritoneal cavity. The patient becomes febrile and third space loss of fluid in peritoneal cavity and sepsis result in hypotension and circulatory collapse. The patient may also develop electrolyte imbalance and renal failure.
Practice Paper 7: Answers
Anthony B. Starr, Hiruni Jayasena, David Capewell, Saran Shantikumar in Get ahead! Medicine, 2016
Torsades de pointes is seen on ECG as a regular broad complex tachycardia with a varying axis whereby the QRS complexes repeatedly switch from an upright to a horizontal position. The patient often experiences palpitations, dizziness, chest pain and syncope. The rhythm usually aborts spontaneously, but has the potential to degenerate into ventricular fibrillation. Prolonged episodes of torsades de pointes that are associated with haemodynamic instability require urgent DC cardioversion. Long-term management includes β-blockade (not in acquired disease, as it may trigger torsades de pointes), permanent pacemakers in severe symptomatic disease and implantable cardioverter–defibrillators in patients at high risk of sudden cardiac death. In cases of acquired disease, any electrolyte imbalance must be corrected and offending drugs stopped.
Water and foodborne contamination *
Jamie Bartram, Rachel Baum, Peter A. Coclanis, David M. Gute, David Kay, Stéphanie McFadyen, Katherine Pond, William Robertson, Michael J. Rouse in Routledge Handbook of Water and Health, 2015
Infection due to contaminated food and water is typically caused by the following bacteria: Salmonella spp., Shigellaspp., Campylobacterspp., Listeria monocytogenes, and pathogenic E. coli (Cliver et al., 2011). Salmonellaspp. and Shigellaspp. infections cause diarrhea, fever, cramps, blood loss, vomiting, and/or potentially death. SalmonellaTyphi, a serovar of Salmonella enterica, can cause more severe complications, including jaundice, intestinal bleeding, myocarditis, and encephalothopy. Campylobacterspp. infection is characterized by acute diarrhea, abdominal cramping, fever, and bloody stools. L. monocytogenes infections are characterized by fever, diarrhea, sepsis, meningoencephalitis, and potentially abortion or fetal damage. Diarrheagenic E. coli(e.g., enteroaggregative, enterohemorragic, enteroinvasive, enteropathogenic, and enterotoxigenic) infections result in symptoms of diarrhea, vomiting, hemolytic-uremic syndrome, renal failure, and death. Notably, enterotoxigenic E. coliis one of the four etiological agents most responsible for moderate-to-severe diarrhea in children under five globally (Kotloff et al., 2013). Other important waterborne pathogens associated with foodborne outbreaks include Vibrio cholerae, V. parahaemolytics, and V. vulnificus (Cliver et al., 2011). Vibriospp. infection symptoms include vomiting, diarrhea, abdominal pain, and potentially septic shock. Cholera infections may cause diarrhea and vomiting so severe that dehydration and electrolyte imbalance lead to death.
Peptide receptor radionuclide therapy in neuroendocrine neoplasms and related tumors: from fundamentals to personalization and the newer experimental approaches
Published in Expert Review of Precision Medicine and Drug Development, 2023
These are mainly related to the AA infusion used for renal protection (for details see PROCEDURE section of the chapter). Co-infusion of this AA raises a state of metabolic acidosis and causes symptoms like nausea, vomiting, abdominal discomfort, and headaches. Different centers have reported varying ranges of these effects (vomiting in 10%, significant nausea 25%) as a reporting system and threshold of the reference population. There also occurs a mild degree of electrolyte imbalance especially hyperkalemia and hypernatremia during this period [33]. Caution should be taken if there is severe nausea/vomiting precipitating a state of significant dehydration and thereby could further worsen the electrolyte imbalance. For all patients precautionary measures are taken using a combination of corticosteroid and antiemetic administration before PRRT. Some of these patients require repeat administration of this or consideration of drugs like aprepitant for symptom control. Adequate patient counseling, preparation, and hydration form the backbone of facing these effects.
Indwelling tunneled pleural catheters in patients with hepatic hydrothorax: A single-center analysis for outcomes and complications
Published in Canadian Journal of Respiratory, Critical Care, and Sleep Medicine, 2023
Fatmah F. Alhabeeb, Katia Carle-Talbot, Natalie Rakocevic, Tinghua Zhang, Michael Mitchell, Kayvan Amjadi, Chanel Kwok
Conventional chest tube placement is rarely a favorable option for refractory hydrothorax because of rapid fluid re-accumulation after removal of the chest tube. This intervention is also associated with potential complications including electrolyte imbalance, renal failure, protein loss and increased risk of infection.6 Furthermore, due to the continuous production of the effusion, successful removal of the chest tube is challenging as the minimal drainage volume that traditionally implies safe removal is rarely achieved. TIPS requires high level of expertise that is not available at every center. Often, there are greater contraindications than indications, limiting the number of appropriate candidates. Furthermore, loco-regional criteria for liver transplant candidacy are quite variable. Often patients are excluded based on their age or comorbidities. Those that do qualify may endure a significant wait time due to scarcity of resources. Thus, there is a need for an alternative therapy either for palliation or as a bridge to transplantation.
The clinical impact of paroxysmal arrhythmias on the hospital outcomes of patients admitted with cirrhosis: propensity score matched analysis of 2011–2017 US hospitals
Published in Expert Review of Cardiovascular Therapy, 2021
David Uihwan Lee, Gregory Hongyuan Fan, David Jeffrey Hastie, Elyse Ann Addonizio, Raffi Karagozian
Given the findings from this study, it may be reasonable to stratify high-risk patients with cirrhosis who have preexisting cardiac abnormalities and structural aberrations in early admission; following, if there are abnormalities noted in the admission electrocardiogram, follow-up monitoring with telemetry may be considered [61]. Electrolytes should be routinely monitored to ensure that electrolyte imbalance and deficits are corrected – as to prevent the possibility of PA events [62]. In the setting of frequent and symptomatic PA events, it may be reasonable to consult electrophysiology or cardiology to discuss the clinical benefits of providing conduction-altering therapies, including ablation and implantable devices, to prevent serious cardiac events [49,50]. In such cases, the patients may require atrioventricular node-blocking medications and further cardiac work-up to identify causes of PA events – which may include ischemic work-up through cardiac catheterization or structural evaluation with an echocardiogram [49,50].