Bleeding in the Digestive Tract
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Small Bowel Obstruction After Laparoscopic Roux-En-Y Gastric Bypass Presenting As Acute Pancreatitis: a Case Report
Netherlands Journal of Critical Care Submitted January 2018; Accepted April 2018 CASE REPORT Small bowel obstruction after laparoscopic Roux-en-Y gastric bypass presenting as acute pancreatitis: a case report N. Henning1, R.K. Linskens2, E.E.M. Schepers-van der Sterren3, B. Speelberg1 Department of 1Intensive Care, 2Gastroenterology and Hepatology, and 3Surgery, Sint Anna Hospital, Geldrop, the Netherlands. Correspondence N. Henning - [email protected] Keywords - Roux-en-Y, gastric bypass, pancreatitis, pancreatic enzymes, small bowel obstruction, biliopancreatic limb obstruction. Abstract Small bowel obstruction is a common and potentially life-threatening bowel obstruction within this complication after laparoscopic Roux-en-Y gastric bypass surgery. population, because misdiagnosis We describe a 30-year-old woman who previously underwent can have disastrous outcomes.[1,3-5,7] gastric bypass surgery. She was admitted to the emergency In this report we describe the department with epigastric pain and elevated serum lipase levels. difficulty of diagnosing small Conservative treatment was started for acute pancreatitis, but she bowel obstruction in post- showed rapid clinical deterioration due to uncontrollable pain and LRYGB patients and why frequent excessive vomiting. An abdominal computed tomography elevated pancreatic enzymes scan revealed small bowel obstruction and surgeons performed can indicate an obstruction in an exploratory laparotomy with adhesiolysis. Our patient quickly these patients. The purpose of improved after surgery and could be discharged home. This case this manuscript is to emphasise report emphasises that in post-bypass patients with elevated Figure 1. Roux-en-Y gastric bypass that in post-bypass patients with pancreatic enzymes, small bowel obstruction should be considered ©Ethicon, Inc. -
Abdominal Pain - Gastroesophageal Reflux Disease
ACS/ASE Medical Student Core Curriculum Abdominal Pain - Gastroesophageal Reflux Disease ABDOMINAL PAIN - GASTROESOPHAGEAL REFLUX DISEASE Epidemiology and Pathophysiology Gastroesophageal reflux disease (GERD) is one of the most commonly encountered benign foregut disorders. Approximately 20-40% of adults in the United States experience chronic GERD symptoms, and these rates are rising rapidly. GERD is the most common gastrointestinal-related disorder that is managed in outpatient primary care clinics. GERD is defined as a condition which develops when stomach contents reflux into the esophagus causing bothersome symptoms and/or complications. Mechanical failure of the antireflux mechanism is considered the cause of GERD. Mechanical failure can be secondary to functional defects of the lower esophageal sphincter or anatomic defects that result from a hiatal or paraesophageal hernia. These defects can include widening of the diaphragmatic hiatus, disturbance of the angle of His, loss of the gastroesophageal flap valve, displacement of lower esophageal sphincter into the chest, and/or failure of the phrenoesophageal membrane. Symptoms, however, can be accentuated by a variety of factors including dietary habits, eating behaviors, obesity, pregnancy, medications, delayed gastric emptying, altered esophageal mucosal resistance, and/or impaired esophageal clearance. Signs and Symptoms Typical GERD symptoms include heartburn, regurgitation, dysphagia, excessive eructation, and epigastric pain. Patients can also present with extra-esophageal symptoms including cough, hoarse voice, sore throat, and/or globus. GERD can present with a wide spectrum of disease severity ranging from mild, intermittent symptoms to severe, daily symptoms with associated esophageal and/or airway damage. For example, severe GERD can contribute to shortness of breath, worsening asthma, and/or recurrent aspiration pneumonia. -
Evidence Vs Experience in the Surgical Management of Necrotizing Enterocolitis and Focal Intestinal Perforation
Journal of Perinatology (2008) 28, S14–S17 r 2008 Nature Publishing Group All rights reserved. 0743-8346/08 $30 www.nature.com/jp ORIGINAL ARTICLE Evidence vs experience in the surgical management of necrotizing enterocolitis and focal intestinal perforation CJ Hunter1,2, N Chokshi1,2 and HR Ford1,2 1Department of Surgery, University of Southern California Keck School of Medicine, Los Angeles, CA, USA and 2Department of Surgery, Childrens Hospital Los Angeles, Los Angeles, CA, USA bacterial colonization and prematurity.4 There is a subset of low Introduction: Necrotizing enterocolitis (NEC) and focal intestinal birth weight infants, however, that sustain focal intestinal perforation (FIP) are neonatal intestinal emergencies that affect premature perforation (FIP) without classic clinical, radiographic, or infants. Although most cases of early NEC can be successfully managed with histological evidence of NEC.5 FIP appears to be a distinct clinical medical therapy, prompt surgical intervention is often required for advanced entity that occurs in 3% of very low birth weight (VLBW) infants or perforated NEC and FIP. and accounts for 44% of gastrointestinal perforations in this 6 Method: The surgical management and treatment of FIP and NEC are population. Optimal surgical management of severe NEC and discussed on the basis of literature review and our personal experience. FIP has been the subject of ongoing controversy for many years. Result: Surgical options are diverse, and include peritoneal drainage, laparotomy with diverting ostomy alone, laparotomy with intestinal Presentation of NEC and FIP resection and primary anastomosis or stoma creation, with or without Infants with NEC typically present with feeding intolerance and second-look procedures. -
Diagnostic Direct Laryngoscopy, Bronchoscopy & Esophagoscopy
Post-Operative Instruction Sheet Diagnostic Direct Laryngoscopy, Bronchoscopy & Esophagoscopy Direct Laryngoscopy: Examination of the voice box or larynx (pronounced “lair-inks”) under general anesthesia. An instrument called a laryngoscope is carefully placed into the mouth and used to visualize the larynx and surrounding structures. Bronchoscopy: Examination of the windpipe below the voice box in the neck and chest under general anesthesia. A long narrow telescope is passed through the larynx and used to carefully inspect the structures of the trachea and bronchi. Esophagoscopy: Examination of the swallowing pipe in the neck and chest under general anesthesia. An instrument called an esophagoscope is passed into the esophagus (just behind the larynx and trachea) and used to visualize the mucus membranes and surrounding structures of the esophagus. Frequently a small biopsy is taken to evaluate for signs of esophageal inflammation (esophagitis). What to Expect: Diagnostic airway endoscopy procedures generally take about 45 minutes to complete. Usually the procedure is well-tolerated and the child is back-to-normal the next day. Mild throat or tongue discomfort may persist for a few days after the procedure and is usually well-controlled with over-the-counter acetaminophen (Tylenol) or ibuprofen (Motrin). Warning Signs: Contact the office immediately at (603) 650-4399 if any of the following develop: • Worsening harsh, high-pitched noisy-breathing (stridor) • Labored breathing with chest retractions or flaring of the nostrils • Bluish discoloration of the lips or fingernails (cyanosis) • Persistent fever above 102°F that does not respond to Tylenol or Motrin • Excessive coughing or respiratory distress during feeding • Coughing or throwing up bright red blood • Excessive drowsiness or unresponsiveness Diet: Resume baseline diet (no special postoperative diet restrictions). -
Laryngeal Endoscopy (Rigid, Flexible, and Stroboscopy)
Laryngeal Endoscopy (Rigid, Flexible, and Stroboscopy) Visualization of the larynx can be performed via several different methods. Special tools are required for laryngeal evaluation. Mirror laryngoscopy (1) o While the patient’s tongue is protruded, a mirror is placed in the posterior oropharynx with gentle pressure on the soft palate while light is reflected caudally into the larynx. o Mirror laryngoscopy can be challenging for both the examiner and the patient, has limited magnification, and may require topical anesthesia. o Mirror laryngoscopy provides the most accurate color representation of laryngeal and pharyngeal tissue because there is no light or digital distortion. Flexible laryngoscopy (2) o A flexible laryngoscope is placed into the nasal cavity, through the naso- and oropharynx and positioned cephalad to the larynx for a full laryngeal assessment. o Nasal anesthesia (lidocaine) and/or nasal decongestants (oxymetazoline/phenylephrine) may be applied to the nose for the purpose of improving patient comfort and tolerance o Supplemental procedures such as dynamic voice assessment (comprehensive laryngeal movement evaluation), functional endoscopic evaluation of swallowing (+/- sensory testing), and other laryngeal procedures (ex. injections, laser surgery, biopsies) can be performed during flexible laryngoscopy. o Flexible laryngoscopy is ideal for evaluating vocal fold weakness, real-time/unencumbered evaluation of task-specific abnormalities (ex. my voice is problematic when I do this), and assessing the intensity of glottal attack. Rigid Laryngoscopy (3) o Rigid laryngoscopy is performed by placing a rigid 70- or 90-degree telescope into the oropharynx during tongue protrusion. o Sometimes, oropharyngeal and/or tongue application of anesthesia (ex. lidocaine, cetacaine) can be helpful for patient tolerance. -
Exploratory Laparotomy.Docx
EXPLORATORY LAPAROTOMY CONSENT FORM Your physician has determined that you may have a disease or abnormality inside your abdomen which may be life threatening, preventing pregnancy or causing medical problems if not treated. An exploratory laparotomy is an operation in which the doctor makes a surgical “cut” in the belly. Sometimes this operation is done to make sure that no disease or abnormality exists. If the physician finds that a disease is found or if the physician doesn’t feel that corrective surgery should be done immediately, then he will close up the surgical cut. If major corrective surgery is done the risk will be greater than if no corrective surgery is done. It is possible that you will be worse after the operation. Your physician can make no guarantee as to the result that might be obtained from this operation. Complications from exploratory surgery of the abdomen without any corrective surgery are infrequent, but they do occur. As with any surgical procedure, complications from bleeding and infection can occur. These complications can result in prolonged illness, the need for blood transfusions, poor healing wounds, scarring and the need for further operations. Other uncommon complications of this operation include: Damage to the intestines, blocked bowels, hernia or “rupture” developing at the site of the surgical cut, heart attacks or stroke, blood clots in the lungs and pneumonia. Some complications of exploratory surgery of the abdomen may require further surgery, some can cause permanent deformity and rarely, some can even be fatal. Furthermore, there may be alternative therapeutic or diagnostic methods available to you in addition to exploratory surgery. -
Eosinophilic Gastroenteritis Presenting with Severe Anemia and Near Syncope
J Am Board Fam Med: first published as 10.3122/jabfm.2012.06.110269 on 7 November 2012. Downloaded from BRIEF REPORT Eosinophilic Gastroenteritis Presenting with Severe Anemia and Near Syncope Nneka Ekunno, DO, MPH, Kirk Munsayac, DO, Allen Pelletier, MD, and Thad Wilkins, MD Eosinophilic gastrointestinal disorders or eosinophilic digestive disorders encompass a spectrum of rare gastrointestinal disorders that includes eosinophilic esophagitis, eosinophilic gastroenteritis, and eosinophilic colitis. Eosinophilic gastroenteritis is a rare inflammatory disease characterized by eosino- philic infiltration of the gastrointestinal tract. The clinical manifestations include anemia, dyspepsia, and diarrhea. Endoscopy with biopsy showing histologic evidence of eosinophilic infiltration is consid- ered definitive for diagnosis. Corticosteroid therapy, food allergen testing, elimination diets, and ele- mental diets are considered effective treatments for eosinophilic gastroenteritis. The treatment and prognosis of eosinophilic gastroenteritis is determined by the severity of the clinical manifestations. We describe a 24-year-old woman with eosinophilic gastroenteritis presenting as epigastric pain with a history of severe iron deficiency anemia, asthma, eczema, and allergic rhinitis, and we review the litera- ture regarding presentation, diagnostic testing, pathophysiology, predisposing factors, and treatment recommendations. (J Am Board Fam Med 2012;25:913–918.) Keywords: Case Reports, Eosinophilic Gastroenteritis, Gastrointestinal Disorders copyright. A 24-year-old nulliparous African-American woman During examination, her height was 62 inches, was admitted after an episode of near syncope asso- weight 117 lb, and body mass index 21.44 kg/m2. Her ciated with 2 days of fatigue and dizziness. She re- heart rate was 111 beats per minute, blood pressure ported gradual onset of dyspepsia over 2 to 3 121/57 mm Hg, respiratory rate 20 breaths per minute, months. -
Gastroesophageal Reflux Disease (GERD)
Guidelines for Clinical Care Quality Department Ambulatory GERD Gastroesophageal Reflux Disease (GERD) Guideline Team Team Leader Patient population: Adults Joel J Heidelbaugh, MD Objective: To implement a cost-effective and evidence-based strategy for the diagnosis and Family Medicine treatment of gastroesophageal reflux disease (GERD). Team Members Key Points: R Van Harrison, PhD Diagnosis Learning Health Sciences Mark A McQuillan, MD History. If classic symptoms of heartburn and acid regurgitation dominate a patient’s history, then General Medicine they can help establish the diagnosis of GERD with sufficiently high specificity, although sensitivity Timothy T Nostrant, MD remains low compared to 24-hour pH monitoring. The presence of atypical symptoms (Table 1), Gastroenterology although common, cannot sufficiently support the clinical diagnosis of GERD [B*]. Testing. No gold standard exists for the diagnosis of GERD [A*]. Although 24-hour pH monitoring Initial Release is accepted as the standard with a sensitivity of 85% and specificity of 95%, false positives and false March 2002 negatives still exist [II B*]. Endoscopy lacks sensitivity in determining pathologic reflux but can Most Recent Major Update identify complications (eg, strictures, erosive esophagitis, Barrett’s esophagus) [I A]. Barium May 2012 radiography has limited usefulness in the diagnosis of GERD and is not recommended [III B*]. Content Reviewed Therapeutic trial. An empiric trial of anti-secretory therapy can identify patients with GERD who March 2018 lack alarm or warning symptoms (Table 2) [I A*] and may be helpful in the evaluation of those with atypical manifestations of GERD, specifically non-cardiac chest pain [II B*]. Treatment Ambulatory Clinical Lifestyle modifications. -
Gastroesophageal Reflux Disease
The new england journal of medicine clinical practice Gastroesophageal Reflux Disease Peter J. Kahrilas, M.D. This Journal feature begins with a case vignette highlighting a common clinical problem. Evidence supporting various strategies is then presented, followed by a review of formal guidelines, when they exist. The article ends with the author’s clinical recommendations. A 53-year-old man, who is otherwise healthy and has a 20-year history of occasional heartburn, reports having had worsening heartburn for the past 12 months, with daily symptoms that disturb his sleep. He reports having had no dysphagia, gastroin- testinal bleeding, or weight loss and in fact has recently gained 20 lb (9 kg). What would you advise regarding his evaluation and treatment? The Clinical Problem From the Division of Gastroenterology, Gastroesophageal reflux disease is the most common gastrointestinal diagnosis re- Feinberg School of Medicine, Chicago. Ad- corded during visits to outpatient clinics.1 In the United States, it is estimated that dress reprint requests to Dr. Kahrilas at the Feinberg School of Medicine, 676 St. Clair 14 to 20% of adults are affected, although such percentages are at best approxima- St., Suite 1400, Chicago, IL 60611-2951, tions, given that the disease has a nebulous definition and that such estimates are or at [email protected]. based on the prevalence of self-reported chronic heartburn.2 A current definition of N Engl J Med 2008;359:1700-7. the disorder is “a condition which develops when the ref lux of stomach contents causes Copyright © 2008 Massachusetts Medical Society. troublesome symptoms (i.e., at least two heartburn episodes per week) and/or complications.”3 Several extraesophageal manifestations of the disease are well rec- ognized, including laryngitis and cough (Table 1). -
Flexible Sigmoidoscopy – Outpatients
Flexible sigmoidoscopy – Outpatients You have been referred by your doctor to have a flexible sigmoidoscopy. his information booklet has been written to explain the procedure. This will help you to make an informed decision before consenting to the procedure. If you are unable to attend your appointment please inform us as soon as possible. Please ensure you read this booklet and the enclosed consent form thoroughly. Please also complete the enclosed health questionnaire. You may be contacted by an endoscopy trained nurse before your procedure to go through the admission process and answer any queries you may have. If you are not contacted please come to your appointment at the time stated in your letter. Please note your appointment time is your arrival time on the unit and not the time of your procedure. If you have any mobility issues or if there is a possibility you could be pregnant, please contact the appointment staff on 01284 713551 Please remember there will be other patients in the unit who may arrive after you but are taken in for their procedure before you, this is for medical reasons or they are seeing a different doctor. Due to limited space available and to maintain other patients’ privacy and dignity, we only allow patients (and carers) through to the ward area. Relatives/ escorts will be contacted once you are ready for collection. The Endoscopy Unit endeavours to offer single sex facilities, and we aim to make you stay as comfortable and stress free as possible. Source: Endoscopy Reference No: 5035-14 Issue date: 8/1/21 Review date: 8/1/24 Page 1 of 11 Medication If you are taking WARFARIN, CLOPIDOGREL, RIVAROXABAN or any other anticoagulant (blood thinning medication), please contact the appointment staff on 01284 713551, your GP or anticoagulation nurse, as special arrangements may be necessary. -
Abdominal Exploratory and Closure
Abdominal exploratory and closure 10.1 Diagnostic procedures 10.1.1 Paracentesis 10.1.1.1 Paracentesis technique 10.1.2 Enterocentesis 10.1.2.1 Enterocentesis technique 10.2 Opening of the abdominal cavity 10.2.1 Introduction 10.2.2 Position of the animal 10.2.3 Location of incision 10.2.4 Type of incision 10.2.4.1 Through-and-through incision 10.2.4.2 Complete grid Incision 10.2.4.3 Partial grid incision 10.2.5 Laparotomy in the bovine 10.2.5.1 Indications 10.2.5.2 Through-and-through incision 10.2.5.3 Partial grid incision 10.2.5.4 Complete grid incision 10.2.6 Laparotomy in small ruminants Chapter 10 10.2.7 Laparotomy in the horse 10.2.7.1 Indications 10.2.7.2 The median coeliotomy 10.2.7.3 The paramedian laparotomy 10.2.8 Coeliotomy in the dog and the cat 10.2.8.1 Indications 10.2.8.2 The median coeliotomy 10.2.8.3 The flank or paracostal incision 10.3 Minimally invasive techniques 10.4 Abdominal procedures 10.4.1 The rumen (bovine, small ruminants) 10.4.1.1 Introduction 10.4.1.2 Rumenotomy 10.4.2 The abomasum (bovine) 10.4.3 The stomach (horse, dog and cat) 10.4.3.1 Introduction 10.4.3.2 Gastrotomy in the dog and the cat 10.4.4 The small- and large intestines 10.4.4.1 Introduction 10.4.4.1.1 Simple mechanical ileus 10.4.4.1.2 Strangulating ileus 10.4.4.1.3 Paralytic ileus 10.4.4.2 Diagnostics 10.4.4.3 Therapy 10.4.4.3.1 Enterotomy 10.4.4.3.2 Enterectomy 10.4.5 The bladder 10.4.5.1 Introduction 10.4.5.2 Urolithiasis in bovine and equine 10.4.5.3 Cystotomy in the horse 10.4.5.3.1 Laparocystotomy 10.4.5.3.2 Pararectal cystotomy 10.4.5.4 Urolithiasis in the dog and the cat 10.4.5.5 Cystotomy in the dog and the cat 10.4.6 The uterus 10.4.6.1 Opening and closing of the uterus 10.4.6.2 Ovariectomy and ovariohysterectomy in dog and cat Chapter 10 176 Chapter 10 Abdominal exploratory and closure 10.1 Diagnostic procedures 10.1.1 Paracentesis paracentesis Paracentesis is the puncturing of the abdominal cavity. -
SPECIALTY CARE Digestive Health
SPECIALTY CARE Digestive Health Through our Day Kimball Medical Group A lot of people care about your health. Including us. So if you’re 45 or practices and other associated specialty over and due for a colon screening, you should know that Day Kimball physicians, Day Kimball Healthcare has one of the most comprehensive digestive health programs around. provides you access to expert specialized care for virtually every body system Gastroenterology deals with the function, diseases and disorders of and condition, within an integrated and the digestive system, including the esophagus, stomach, pancreas, gall coordinated approach. bladder, bile ducts, liver, small intestine, colon (or large intestine), and rectum. Most everyone will need specialized care at some point in life. It’s good to know Physician Consultations that when that time comes you’ll have Consults for advanced treatment of digestive and liver disorders are access to physicians and facilities focused available through our associated board-certified gastroenterologists solely on providing you with top-notch from Connecticut GI. A referral from your primary care practitioner specialized care, close to home. (PCP) is required. Day Kimball Healthcare offers integrated, comprehensive care Endoscopy Services With our state-of-the-art Doris E. Madeira Endoscopy Suite at Day close to home. To learn more Kimball Hospital and the services of our associated gastroenterologists about all of our specialty from Connecticut GI, we are able to offer comprehensive screening, medical services