Morbidity and Mortality Conference. R 李向嚴 Department of Internal Medicine Taipei Medical University Hospital
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1 Morbidity and Mortality Conference R 李向嚴 Department of Internal Medicine Taipei Medical University Hospital
2 Basic data 解張 O 蘇 Age : 82 Gender:female Height : 156 Weight : BMI : 23 Time of Admission : 107/09/29 12:14 Native: 台灣省 Residence: 台北市 Marital Status: 喪偶 Education: 小學 Occupation: 無
3 Chief Complaint Aggravated epigastric pain with heart burn sensation about 2 days
4 Brief Admission HPI Epigastric pain with nausea sensation & acid regurgitation since 1 day before admission abdominal fullness & poor appetite since half year before severe epigastric colicky pain (VAS 7 8/10) in recent 2 months intermittently pain exaggerated after meal but got relieved after anti acid drugs s/s would mildly relieved after vomiting with gastric juicy content denied fever/chills, cough, dyspnea, chest pain, back pain, shoulder pain, bloody/black stool or limbs edema no Chinese herbal/steroid/nsaids medication using
5 HPI Panendoscopy examination on 107/09/12 with report as several gastric ulcer and H.P infection under eradication since 107/09/21 (Amoxcillin+Clarithomycin+Lansoprazole) no stool passage in recent 2 days decreased urine amount about 2 days frequent attack of palpitation with headache during this year body weight loss (5kg/6months)
6 2018/09/12: 5cm bezoar on fundus
7 PMH 1. HTN 2. Cardiac arrhythmia 3. GU under triple therapy since 09/21 4. UGI bleeding history 5. HIVD, lumbar 4/5 with spinal stenosis, and radiculopathy in 105/11 PSH 1. R t total knee arthroplasty in 106/03 2. L t total knee arthroplasty years ago 3. Compression fracture at L1 and L3 vertebrae s/p vertebroplasty at L1 level 4. S/P interbody fusion with cage placement at L4 5 level FH Noncontributory SH Denies x3 Medications 1. Diovan 40mg QD 2. Arrythmia under Inderal 5mg QD 3. Amoxicillin 1g BID + Clarithromycin 500mg BID + Lansoprazole 30mg QDAC Allergies Nil.
8 PE General appearance Ill looking Consciousness: E4V5M6 BT: 36.7 C, HR: 74/min, RR: 16/min, BP: 147/96 mmhg, SpO2: 100%. HEENT no JVE Conjunctiva pallor: ( ) Sclera icteric ( ) Lymph node( ) Chest No deformity Breath sound: clear Heart: Irregular rhythm grade 2/6 mid systolic murmur at apex area Abdomen Bowel sounds: hyper active Epigastric tenderness(+) No rebounding pain Muscle guarding ( ) Extremities Range of motion: full and free No skin lesion Peripheral cyanosis ( ) Clubbing of finger ( ) Limbs edema ( ) Skin Skin turgor: decrease Cyanosis ( )
9 Initial Labs Blood cell count Liver function test Basic metabolic panel Cardiac Enzyme WBC: 8140/uL (i) Neutrophils: 72% (ii) Lymphocytes: 17.9% (iii) Monocytes: 5.9% GOT: 16 GPT: 11 BUN: 20 Cr: 1.1 Platelets: /uL Total bilirubin: 0.5 Na: 132 K: 3.7 CK: 100 CKMB: 25 Troponin T: Hb: 14.0 HCT: 41.2% MCV: 82.4 r GT: 11 Lipase: 47 CRP: 0.15 OB: +/
10 9/29
11 9/6
12
13 Initial Studies EKG: SR, newly developed diffuse T wave inversion (comparing with 2018/09/06) Echocardiography = EF 60 65%, mild AR/MR No IVC engorgement no pericardial effusion
14 9/29 CXR
15 9/29 KUB
16 Epigastric pain D/D Diagnosis Findings More Consistent with Diagnosis Less Consistent with Diagnosis Findings GERD Heart burn sensation Myocardial Infarction Cardiac enzyme, diffuse T wave No shortness of breath inversion Peptic ulcer Epigastric pain Gastritis Epigastric pain Acute pancreatitis N/V No radiation pain to back, No elevated Lipase Chronic pancreatitis N/V No radiation pain to back Acute cholecystitis N/V No radiation pain to shoulder No elevated r GT Pericarditis no pericardial effusion
17 Initial Impression 1. suspect ischemic heart disease, must rule out non ST segment elevation acute coronary syndrome, to rule out coronary artery spasm 2. gastric ulcer and reflux esophagitis 3. dehydration
18 Management suspect ischemic heart disease R/O coronary artery spasm, add non DHP CCB (diltiazem 15mg BID) arrange Tl 201, and Holter for etiology following serial cardiac enzyme and EKG for ACS gastric ulcer & reflux esophagitis arrange abdominal CT, if still severe abdominal pain
19 Intermittent abdominal pain Thallium scan Holter f/u KUB: no ileus
20
21 24hr Holter Rate from bpm
22 Cardiac enzyme f/u 9/29 9/30 10/1 CK CKMB Troponin T
23 10/2 KUB
24 a distended stomach with an air-fluid level outlining a large gastric bezoar (arrows) UpToDate
25 Intermittent abdominal pain DC Clarithromycin DC Amoxicillin
26
27 Check GDH/toxin ( ) Intermittent abdominal pain panendoscopy diarrhea BP drop N/S 1 bot full run f/u KUB
28 10/4 Panendoscopy
29 10/8 KUB
30 Intermittent abdominal pain f/u KUB CT
31 10/10 KUB
32
33 Surgery transfer to ICU Intermittent abdominal pain f/u KUB CT Remove endotracheal tube
34
35 laparoscopic segmental resection of small bowel with primary side to side anastomosis, SILS method
36 admit Timeline of Events f/u KUB: no ileus Thallium scan Holter DC Clarithromycin Panendoscopy: Gastric ulcer + disappear of bezoar f/u KUB: no ileus KUB: ileus CT: total small bowel obstruction => surgery Remove endotracheal tube discharge 9/29 10/2 10/4 10/8 10/10 10/11 10/19
37 small bowel bezoar with total obstruction and small bowel ischemia change a hard bezoar measuring 4.5x3x3 and one segment of small intestine, measuring 6.5 cm in length mucosa shows reddish and ischemic change
38 Final Diagnosis 1. Acute obstructive ileus related to bezoar impaction with total bowel obstruction over terminal ileum areas post laparoscopic segmental resection of small bowel with primary side to side anastomosis on 107/10/10 2. gastric ulcer and reflux esophagitis 3. Ischemia heart disease
39 Case Analysis Bezoar caused small bowel obstruction How large should we remove the Bezoar? Abdominal sonogram Does arrange Abd CT earlier helpful for the patient?
40 Discussion
41 Calcareous bezoars mainly gallstones Bezoars Phytobezoars undigested fiber, fruit seeds, or vegetable Trichobezoars balls comprising swallowed hair Foreign stuff Other sources, based on their contents
42 Bezoars Phytobezoar is the predominant type of bezoars causing SBO ileum may be the more susceptible site for SBO resulting from bezoars The terminal of ileum is more susceptible to bezoar induced SBO probably due to its small diameter Lian qin Kuang et. al, 2016
43 Retrospective study Se Heon Oh; J Korean Soc Coloproctol 2012
44 Bezoars Bezoar > 3 cm in diameter is easily impacted in the small bowel, especially the terminal ileum Zissin et al. suggested that bezoars measuring approximately 3 5 cm may be regarded as a pathognomonic CT finding for an obstructing bezoar Kim et al. have also observed that the mean long axis diameter of obstructing bezoars was 5.2 cm Lian qin Kuang et. al, 2016
45 Symptoms of bezoars Nausea and frequent vomiting upper abdominal pain abdominal distension palpable mass weight loss Se Heon Oh; J Korean Soc Coloproctol 2012
46 Symptoms of bezoars Differentiating bowel obstruction caused by adhesion from bowel obstruction caused by a bezoar is not easy in the patients who had previous abdominal surgery and present with symptoms of bowel obstruction Surgical interventions can be delayed, and complications will be increased if bezoar induced small bowel obstruction is misdiagnosed as bowel obstruction caused by adhesion, which may be treated with conservative managements Se Heon Oh; J Korean Soc Coloproctol 2012
47 The diagnostic rate of abdominal ultrasonography is reported to be 88 93% operator dependent accumulated gas in the bowels affecting the ultrasonic sound A small bowel series has an excellent accuracy in differentiating bowel obstruction caused by adhesion from bowel obstruction caused by a bezoar not feasible in cases of complete bowel obstruction or suspected ischemia due to the high risk of bowel perforation contrast used for the test can cause complications in the planned operation Se Heon Oh; J Korean Soc Coloproctol 2012
48 The diagnostic rate of abdominal CT in diagnosing the cause of bowel obstruction: 73 95% diagnostic accuracy for bezoar induced bowel obstruction: % Se Heon Oh; J Korean Soc Coloproctol 2012
49 group w/o CT scan group w/ CT scan w/o bezoar being identified group diagnosed w/ a bezoar by using the CT scan
50 The frequency of postoperative complications secondary to bowel ischemia and bowel necrosis is higher when the diagnosis of bezoarinduced bowel obstruction is delayed Escamilla C, et al., J Am Coll Surg 1994
51 A preoperative diagnosis of bezoar induced small bowel obstruction by using clinical features was difficult Increased use of abdominal CT led to a more accurate diagnosis and to earlier surgery for bezoar induced small bowel obstructions, thereby reducing the rate of complications Se Heon Oh; J Korean Soc Coloproctol 2012
52 Treatment of gastric bezoars chemical dissolution Cellulase: %, expensive Acetylcysteine: 50% Papain: 87%, esophageal perforation Coca Cola: 50%, well tolareted, inexpensive Metoclopramide (adjuvant prokinetics) endoscopy approach 6mm endoscope surgical intervention when conservative management fails
53 Prevention of recurrence ~20% have recurrent bezoars Increase water intake Modify their diet (avoid high fiber foods) Chewing food carefully...
54 Conclusions What happened to the patient? A 5 cm bezoar impacted in her terminal ilium and caused small bowel obstruction What did we learn? Consider remove the bezoar over 3 cm Abdominal CT can lead to earlier surgery for bezoar induced small bowel obstructions
55 Thank you for listening!
56 laparoscopic segmental resection of small bowel with primary side to side anastomosis, SILS method
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