- Email: [email protected]
Feeling bloated
Case Reports [26] Ono Y. Ampulla (Takotsubo) cardiomyopathy associated with subarachnoid hemorrhage worsening in the late phase of vasospasm. Neurol Med Chir (Tokyo) 2004;44:72 - 4. [27] Bybee KA, Prasad A, Barsness GW, et al. Clinical characteristics and Thrombolysis In Myocardial Infarction frame counts in women with transient left ventricular apical ballooning syndrome. Am J Cardiol 2004;94:343 - 6. [28] Nagao T, Ohwada T, et al. Intra-aortic balloon pumping is effective for hemodynamic management of catecholamine resistant ampulla (Takotsubo) cardiomyopathy. Masui 2004;53:799 - 802. [29] Akashi YJ. Left ventricular rupture associated with Takotsubo cardiomyopathy. Mayo Clin Proc 2004;79:821 - 4. [30] Yamamoto Y. Reversible left ventricular dysfunction (Takotsubo cardiomyopathy) with deep negative T waves due to possible cardiac sympathetic denervation. Can J Cardiol 2005;21:181 - 4. [31] Denney SD. Long QT syndrome and torsade de pointes in transient left ventricular apical ballooning syndrome. Int J Cardiol 2005;100: 499 - 501. [32] Ogura R, Hiasa Y, Takahashi T, et al. Specific findings of the standard 12-lead ECG in patients with dTakotsuboT cardiomyopathy: comparison with the findings of acute anterior myocardial infarction. Circ J 2003;67:687 - 90. [33] Vaglio Jr J, Reyburn A, et al. 63-year old woman with acute chest pain. Mayo Clin Proc 2006;81:837 - 40. [34] Akashi YJ. 123I-MIBG myocardial scintigraphy in patients with bTakotsuboQ cardiomyopathy. J Nucl Med 2004;45:1121 - 7. [35] Ibanez B. Takotsubo syndrome: a Bayesian approach to interpreting its pathogenesis. Mayo Clin Proc 2006;81:732 - 5.
207 descending duodenum below the biliary opening was alleviated by the successful placement of a duodenal selfexpandable enteral metal stent (black arrow, panel B). A week after presentation, the patient was discharged home with restored oral intake. Acute massive gastric distension occurs particularly in patients with pathologic eating disorders or superior mesenteric artery syndrome [1] and can cause lethal mucosal ischemia and necrosis [2,3], or mechanical hemodynamic catastrophe [4]. This case of chronic distension secondary to gastric outlet obstruction illustrates a particularly increased proximal gastric compliance [5]. The hyperglycemia [6] and hyperinsulinemia [7] secondary to type 2 diabetes mellitus
Feeling bloated A 58-year-old man with well-controlled type 2 diabetes mellitus was found to have a well-differentiated adenocarcinoma of the head of the pancreas during a workup of jaundice and weight loss. An attempted Whipple procedure was aborted because the mass invaded the superior mesenteric vascular axis, and only a palliative biliary bypass was performed. Two months later, recurrent cholestasis was alleviated by placement of a metallic biliary endoprosthesis followed by 6 weeks of neoadjuvant gemcitabine and external beam radiation therapy. Four months later, the patient reported a 1-week history of nausea, vomiting, and absence of bowel movement. His abdomen was distended, with preserved peristaltic sounds and increased sonority to percussion but no tenderness or guarding. A plain abdominal radiograph taken with the patient standing (Fig. 1) revealed a strikingly distended stomach (40 cm) and proximal duodenum, the previously placed common biliary duct stent (white arrowhead, panel A), the secondary pneumobilia (black arrows, panel A), and metallic clips (white arrows, panel A). A chest radiograph showed a marked elevation of the left hemidiaphragm. The patient presented with a combination of bgastric outlet obstructionQ and severe bgastroparesis.Q A nasogastric tube was placed, releasing 3 L of dark green gastrobiliary secretions. Endoscopic retrograde cholangiopancreatography showed a stricture in the proximal existent stent; therefore, a covered 10 40-mm wall stent (white arrow, panel B) was placed into the migrated stent (white arrowhead, panel B). An obstructing stricture in the
Fig. 1 Abdominal radiograph at presentation (A) reveals striking 40-cm gastric dilatation and pneumobilia; and immediately after placement of a duodenal self-expanding enteral stent (B).
208 have probably contributed to the increased compliance. The paucity of symptoms and their delayed clinical expression support the hypothesis that muscle fiber tension rather than stretching determine cortical stimulation. Whether stretch— and, therefore, volume— [8] or gastric wall tension is the most relevant stimulus for the perception of gastric distension remains to be established [9]. This case illustrates the importance of considering serious gastric dilatation despite the presence of few symptoms. This is particularly relevant in patients with diabetes mellitus and known mechanical gastric outlet compromise such as a tumor of the head of the pancreas. In conclusion, early and accurate diagnosis of severe gastric dilatation is very important to avoid lethal complications. Fadi Braiteh MD Division of Cancer Medicine Section of General Internal Medicine Emergency Medicine The University of Texas M. D. Anderson Cancer Center Houston, TX 77030-4009, USA E-mail address: [email protected] Margaret B. Row MD Division of Internal Medicine Section of General Internal Medicine Emergency Medicine The University of Texas M. D. Anderson Cancer Center Houston, TX 77030-4009, USA doi:10.1016/j.ajem.2006.10.001
Case Reports [9] Distrutti E, Azpiroz F, Soldevilla A, Malagelada JR. Gastric wall tension determines perception of gastric distention. Gastroenterology 1999;116(5):1035 - 42.
Transorbital ventricular decompression in an acutely decompensated hydrocephalic ED patient Hydrocephalus without progressive warning signs resulting in a sudden life-threatening event is underemphasized in the literature [1-4]. Patients typically exhibit symptoms of elevated intracranial pressure but may present with vague nonspecific complaints that are initially misdiagnosed [4-7]. The neurosurgical literature describes various methods for rapid ventricular decompression of acutely decompensated hydrocephalus, including an adaptation of an 18-G needle to drill the forehead [8], use of a battery-operated drill [9], and the transorbital needle technique [10] as reported in this case and adapted from frontal lobotomy [11]. A 22-year-old man presented to the emergency department (ED) complaining of 2 weeks of unremitting nausea, vomiting, headache, dizziness, as well as neck and back pain. His past medical history included disseminated coccidiomycosis and meningitis when he was 16 years old, with intermittent compliance with fluconazole therapy. He was described as thin, lethargic, and slow moving. His physical examination findings were remarkable for tachycardia at 120 bpm. His laboratory results were normal. He was hydrated; the patient was discharged with a diagnosis of gastroenteritis. The patient returned 5 days later with persistent symptoms and new difficulty with walking. His vital signs were normal, and he was in no acute distress. His neurologic examination findings were normal except for those of his being slow to
References [1] Adson DE, Mitchell JE, Trenkner SW. The superior mesenteric artery syndrome and acute gastric dilatation in eating disorders: a report of two cases and a review of the literature. Int J Eat Disord 1997; 21(2):103 - 14. [2] Lunca S, Rikkers A, Stanescu A. Acute massive gastric dilatation: severe ischemia and gastric necrosis without perforation. Rom J Gastroenterol 2005;14(3):279 - 83. [3] Turan M, Sen M, Canbay E, Karadayi K, Yildiz E. Gastric necrosis and perforation caused by acute gastric dilatation: report of a case. Surg Today 2003;33(4):302 - 4. [4] Lewis S, Holbrook A, Hersch P. An unusual case of massive gastric distension with catastrophic sequelae. Acta Anaesthesiol Scand 2005; 49(1):95 - 7. [5] Lee KJ, Vos R, Janssens J, Tack J. Differences in the sensorimotor response to distension between the proximal and distal stomach in humans. Gut 2004;53(7):938 - 43. [6] Hebbard GS, Sun WM, Dent J, Horowitz M. Hyperglycaemia affects proximal gastric motor and sensory function in normal subjects. Eur J Gastroenterol Hepatol 1996;8(3):211 - 7. [7] van Petersen AS, Vu MK, Lam WF, Lamers CB, Ringers J, Masclee AA. Effects of hyperglycaemia and hyperinsulinaemia on proximal gastric motor and sensory function in humans. Clin Sci (Lond) 2000; 99(1):37 - 46. [8] Carmagnola S, Cantu P, Penagini R. Mechanoreceptors of the proximal stomach and perception of gastric distension. Am J Gastroenterol 2005; 100(8):1704 - 10.
Fig. 1 Upper eyelid retraction with downward displacement of the globe for transorbital needle decompression of the lateral ventricle.
207 descending duodenum below the biliary opening was alleviated by the successful placement of a duodenal selfexpandable enteral metal stent (black arrow, panel B). A week after presentation, the patient was discharged home with restored oral intake. Acute massive gastric distension occurs particularly in patients with pathologic eating disorders or superior mesenteric artery syndrome [1] and can cause lethal mucosal ischemia and necrosis [2,3], or mechanical hemodynamic catastrophe [4]. This case of chronic distension secondary to gastric outlet obstruction illustrates a particularly increased proximal gastric compliance [5]. The hyperglycemia [6] and hyperinsulinemia [7] secondary to type 2 diabetes mellitus
Feeling bloated A 58-year-old man with well-controlled type 2 diabetes mellitus was found to have a well-differentiated adenocarcinoma of the head of the pancreas during a workup of jaundice and weight loss. An attempted Whipple procedure was aborted because the mass invaded the superior mesenteric vascular axis, and only a palliative biliary bypass was performed. Two months later, recurrent cholestasis was alleviated by placement of a metallic biliary endoprosthesis followed by 6 weeks of neoadjuvant gemcitabine and external beam radiation therapy. Four months later, the patient reported a 1-week history of nausea, vomiting, and absence of bowel movement. His abdomen was distended, with preserved peristaltic sounds and increased sonority to percussion but no tenderness or guarding. A plain abdominal radiograph taken with the patient standing (Fig. 1) revealed a strikingly distended stomach (40 cm) and proximal duodenum, the previously placed common biliary duct stent (white arrowhead, panel A), the secondary pneumobilia (black arrows, panel A), and metallic clips (white arrows, panel A). A chest radiograph showed a marked elevation of the left hemidiaphragm. The patient presented with a combination of bgastric outlet obstructionQ and severe bgastroparesis.Q A nasogastric tube was placed, releasing 3 L of dark green gastrobiliary secretions. Endoscopic retrograde cholangiopancreatography showed a stricture in the proximal existent stent; therefore, a covered 10 40-mm wall stent (white arrow, panel B) was placed into the migrated stent (white arrowhead, panel B). An obstructing stricture in the
Fig. 1 Abdominal radiograph at presentation (A) reveals striking 40-cm gastric dilatation and pneumobilia; and immediately after placement of a duodenal self-expanding enteral stent (B).
208 have probably contributed to the increased compliance. The paucity of symptoms and their delayed clinical expression support the hypothesis that muscle fiber tension rather than stretching determine cortical stimulation. Whether stretch— and, therefore, volume— [8] or gastric wall tension is the most relevant stimulus for the perception of gastric distension remains to be established [9]. This case illustrates the importance of considering serious gastric dilatation despite the presence of few symptoms. This is particularly relevant in patients with diabetes mellitus and known mechanical gastric outlet compromise such as a tumor of the head of the pancreas. In conclusion, early and accurate diagnosis of severe gastric dilatation is very important to avoid lethal complications. Fadi Braiteh MD Division of Cancer Medicine Section of General Internal Medicine Emergency Medicine The University of Texas M. D. Anderson Cancer Center Houston, TX 77030-4009, USA E-mail address: [email protected] Margaret B. Row MD Division of Internal Medicine Section of General Internal Medicine Emergency Medicine The University of Texas M. D. Anderson Cancer Center Houston, TX 77030-4009, USA doi:10.1016/j.ajem.2006.10.001
Case Reports [9] Distrutti E, Azpiroz F, Soldevilla A, Malagelada JR. Gastric wall tension determines perception of gastric distention. Gastroenterology 1999;116(5):1035 - 42.
Transorbital ventricular decompression in an acutely decompensated hydrocephalic ED patient Hydrocephalus without progressive warning signs resulting in a sudden life-threatening event is underemphasized in the literature [1-4]. Patients typically exhibit symptoms of elevated intracranial pressure but may present with vague nonspecific complaints that are initially misdiagnosed [4-7]. The neurosurgical literature describes various methods for rapid ventricular decompression of acutely decompensated hydrocephalus, including an adaptation of an 18-G needle to drill the forehead [8], use of a battery-operated drill [9], and the transorbital needle technique [10] as reported in this case and adapted from frontal lobotomy [11]. A 22-year-old man presented to the emergency department (ED) complaining of 2 weeks of unremitting nausea, vomiting, headache, dizziness, as well as neck and back pain. His past medical history included disseminated coccidiomycosis and meningitis when he was 16 years old, with intermittent compliance with fluconazole therapy. He was described as thin, lethargic, and slow moving. His physical examination findings were remarkable for tachycardia at 120 bpm. His laboratory results were normal. He was hydrated; the patient was discharged with a diagnosis of gastroenteritis. The patient returned 5 days later with persistent symptoms and new difficulty with walking. His vital signs were normal, and he was in no acute distress. His neurologic examination findings were normal except for those of his being slow to
References [1] Adson DE, Mitchell JE, Trenkner SW. The superior mesenteric artery syndrome and acute gastric dilatation in eating disorders: a report of two cases and a review of the literature. Int J Eat Disord 1997; 21(2):103 - 14. [2] Lunca S, Rikkers A, Stanescu A. Acute massive gastric dilatation: severe ischemia and gastric necrosis without perforation. Rom J Gastroenterol 2005;14(3):279 - 83. [3] Turan M, Sen M, Canbay E, Karadayi K, Yildiz E. Gastric necrosis and perforation caused by acute gastric dilatation: report of a case. Surg Today 2003;33(4):302 - 4. [4] Lewis S, Holbrook A, Hersch P. An unusual case of massive gastric distension with catastrophic sequelae. Acta Anaesthesiol Scand 2005; 49(1):95 - 7. [5] Lee KJ, Vos R, Janssens J, Tack J. Differences in the sensorimotor response to distension between the proximal and distal stomach in humans. Gut 2004;53(7):938 - 43. [6] Hebbard GS, Sun WM, Dent J, Horowitz M. Hyperglycaemia affects proximal gastric motor and sensory function in normal subjects. Eur J Gastroenterol Hepatol 1996;8(3):211 - 7. [7] van Petersen AS, Vu MK, Lam WF, Lamers CB, Ringers J, Masclee AA. Effects of hyperglycaemia and hyperinsulinaemia on proximal gastric motor and sensory function in humans. Clin Sci (Lond) 2000; 99(1):37 - 46. [8] Carmagnola S, Cantu P, Penagini R. Mechanoreceptors of the proximal stomach and perception of gastric distension. Am J Gastroenterol 2005; 100(8):1704 - 10.
Fig. 1 Upper eyelid retraction with downward displacement of the globe for transorbital needle decompression of the lateral ventricle.