Case. Anton Sharapov R5
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1 Case Anton Sharapov R5
2 Disclaimer... Spent 6/12 in the community hospital busy service but reasonable ample time to ponder surgical experience in alternative, non-academic context effect of small place? could be enlightening...
3 Practice of Surgery as War against... Disease ignorance evil etc
4 Fog of war A great part of the information obtained in war is contradictory, a still greater part is false and by far the greater part is doubtful General Karl Von Clausewitz
5 Fog of war trinity : haste, periscope vision, brute force
6 Phase 1: Grand Falls ER 83 yom Consulted re: weakness brought in by staff of Seniors Home ID: Retired Filipino physical education instructor lives in SH
7 HPI: Difficult to elicit Accent, language, plus slurring of speech (post CVA?) No real complaints Vague abdo discomfort Intermittent cramping Occasional dark stools Takes iron
8 ROS No heartburn, no BM frequency change no Nausea/vomiting, no abdo distention Some weight loss noted by outside observers tired no fever/chills/ns/appetite changes/sleep
9 PMH: R CVA with non-resolving L sided sequellae IHD, no MI AF, slow VR HTN Anemia No smoking No Drinking
10 PMH cont d PUD - antrectomy, BII reconstruction Papillary Ca (total thyroidectomy +?Central LND) Post surgery hypothyroidism LHR incarcerated
11 Medications Lanoxin Fe gluconate ECASA Captopril Adalat XL Eltroxin No allergy
12 Fam Hx: Non-contributory difficult to ascertain
13 O/E: Slow AF, BP syst 120 No distress Thin Sallow skin? Filipino complexion Asking for food
14 Exam cont d ENT N, no lymphadenopathy Chest - a/e decreased B/L Abdomen exam unremarkable No hepato/spleeno/megaly Rectal unremarkable
15 Exam cont d: Muscular atrophy L>R L arm contracture No edema/dvt clinically
16 Blood work Hg 84 (102 11/7 ago) low MCV WBC 9.5 ( /7 ago) ALP 240 (410 11/7 ago) N AST, ALT, Cr/lytes Total Bili 27
17 Imaging? Need any initially? Diagnosis?
18 Initial Diagnosis Recent/ongoing/chronic GI Bleed HD stable anemia Need to r/o GI Ca
19 Briefly: Causes of UGIB PUD Ulcer Gastritis Duodenitis MWT Stress (Curling/Cushing) Cancer in the elderly (adeno CA, GIST) W&W (Aortoenteric F, Hemobilia, dielafoy's lesion, etc)
20 Briefly: Causes of LGIB Angiodysplasia Diverticulosis Cancer Ischemic colitis Inflamatory colitis
21 Recurrent PUD? Inadequte surgery: Incomplete vagonomy Retained antrum incomplete excision of paraetal cell mass Stenotic gastric outlet -> stasis Anastomotic ulcer Long afferent loop -> inadequate neutralization of acid)
22 Recurrent PUD Other: H.Pylori re/infection Antral G cell hyperplasia Gastrinoma (MEN 1) Hyperparathyroidism (MEN 1 & 2) Drugs (steroids/nsaids) Bile gastritis (reflux) Gastric bezoar
23 Plan? Admit Medicine service Assess HD stable NPO, IV access OGD to start with...
24 Phase 2: getting out tricoders, periscopes, etc
25 OGD Normal afferent/efferent loop Normal gastric pouch Next?
26 Feed Clear fluids excellent PO intake Teed up for colonoscopy Doing well abdomen gets distended every now and then
27 CT scan ordered looking for masses, nodes, anything untoward
28 CT scan results surgery gets involved when results are reviewed CT shows distal small bowel obstruction and pneumobilia No definite masses/intraluminal stones plan?
29 Re-assess things Stable abdominal distention no N/V on CT SBO No obvious transition point Large bowel decompressed Pneumobilia
30 Causes of pneumobilia Communication with... GI tract outside rare respiratory tract uncommon intrinsic uncommon
31 Pneumobilia: intrinsic Gas forming microorganism in CBD
32 Pneumobilia: outside fistula Penetrating trauma surgical injury to CBD intentional T-tube
33 Pneumobilia: fistula to Resp Bronchobiliary peridiaphragmatic liver abscess erodes into R pleural space pyogenic amoebic hydatid
34 Pneumobilia: GI fistula Non-Gall stone related malignant tumor erosion acute/chronic chole Crohn s diverticulitis perferated duodenal ulcer Gall stone related
35 Causes of pneumbilia AND SBO Rigler s triad ectopic gall stone, SBO, pneumobilia Gall stone ileus: fistula cholecystoduodenal (60%) choledochoduodenal cholecystogastric cholecystocolonic
36 Gall Stone Ileus SBO obstruction 25% in >65yoa terminal ileum>proximal>distal>jejunum>pyloric Bouveret I syndrome pyloric obstruction
37 Bouveret I syndrome
38 Bouveret - Boerhaave syndrome Case described Gall-Stone in pyloris emesis caused Esophageal rupture what s Bouveret II syndrome? Obsolete term for paroxysmal, supraventricular tachycardias
39 DD from gas in portal vein? Most common cause bowel ischemia 15% cases idiopathic Vein - peripheral gas Bili - central gas
40 Portal vein gas
41 Intramural Gas
42 Gall stone Ileus Working diagnosis?
43 Adjunct study? US done no discernable gall bladder what next?
44 Phase 3:Heavy armour Laparotomy Small bowel dilated No gall stone in the ileum Large bowel decompressed Hepatic flexure thick inflammatory infiltrate Fused with liver edge/porta hepatis Wrapped in omentum
45 Plan? Iliostomy created colon decompressed, non-obstructed... would you explore hepatic flexure & fix fistula? Under 9 pm/community hospital conditions? Under any conditions? we did not explore
46 What could it be? Cholecystitis/Gall stone related Gall bladder cancer eroding into colon Colon cancer eroding into liver liver primary? Asian male
47 Post op On the floor did well Malnourished but good PO intake Recovering well POD 17 Fever, otherwise well WBC /7 before, 9.1 now next?
48 CT Emphysematous changes to GB Abscess in pelvis what to do? No facilities for percutaneous drain give Abx for Cholecystitis minilaparotomy for abscess
49 Follow-up Recovered uneventfully Transferred to GP/palliative care Awaiting placement with senior home Cheaper to keep in hospital vs. Seniors home ($1400 vs. $1200)
50 GP requests diagnosis What would you do? Hard pressed to investigate it further taking a look at the total picture overall outlook?colonoscopy Let it be?
51 ... There are a lot of people who are very liberal with our knives Grand Falls community surgeon
52
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