CASE: Segmental Mesenteric vascular Gangrene^-www.drkeyurbhatt.in*

54 yr male with HTN
C/O pain in abdomen for 2 days with distension and agony
No h/o constipation, diarrhoea , Vomiting, fever
CECT S/o:                                          

Pt explored &
Similar findings intra op:

Gangrenous segment resected and Double Barrel loop Ileostomy made..
Pt now out of sepsis and on oral diet in discharge line....

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CASE: INSULINOMA a rare endocrine tumor of pancreas^-www.drkeyurbhatt.in*

47 yrs female with multiple episodes of unconciousness....every time found to be hypoglycemic..
finally diagnosed to have Insulunoma.....by an Eminent physician.

Random Insulin level : 198 (normal is <5)  Parathormone:  Normal ;   Ca ++ : normal
(no e/o MEN1 or MEN 2B)

MRI s/o

surrounded by vital structures

CECT S/o:

just few mm away from main pancreatic duct

SURGERY: Enucleation of tumor....

Intra Op: 10 % dextrose infusion was given @ 100 ml / hr to prevent hypoglycemia...and thanks to anesthetist who kept pt stable through out surgery and was hardly 50 ml blood loss...

post operatively pt doing well... started on oral diet...sugars are normal...
shifted to General ward (POD - 3)

http://drkeyurbhatt.blogspot.com/2011/02/insulinoma.html

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CASE : Acute on chronic Mesenteric Ischemia with multiple abdominal visceral involvement^-www.drkeyurbhatt.in*

52 yrs female with HTN had agonising abdominal pain for a day...Admitted to a surgeon's place....X-ray , USG: Did not show any abnormality and TLC was near normal..
but severe pain in abdomen----surgeon Doctor promptly advised for CECT abdomen suspecting MAT(Mesenteric Arterial thrombosis)..
And was right in Diagnosis

pt had a very bad CECT Picture:

Immediately underwent Mesenteric angio and Inj Heparin was started in infusion...
Fortunately by angiography Hepatic artery, spleenic artery, IMA and celiac was opened...pulse injection of PAPAVERIN Was given in vessels...and catheter was left in SMA for cont infusion...

Next day pt had relief in Pain but started developing metabolic acidosis in ABG (FIRST MARKER OF BOWEL ISCHEMIA --Even before pulse and BP Alteration )
Repeat ABG in afternoon showed marked drop in Ph and severe metabolic acidosis...

Heparin stopped, Protamine given and taken up for surgery...

fortunately she is saved of LIVER, SPLEEN,KIDNEY PROXYMAL 2 FEET OF SMALL BOWEL AND ASCENDING COLON ONWARDS LARGE BOWEL....

ALL BECAUSE OF EARLY SUSPECTING , CECT ( by primary consultant within 12hrs ) &  INTERVENTION (by Intervention radiologist) AND TIMELY ACTION (surgery) WHICH IS REALLY DIFFICULT AND VERY LESS OFTEN POSSIBLE...but a team effort made it possible...

Pt was saved going into septecemia and shock and now on re-feeding of stoma contents with oral diet and antico-agulants....ambulant in ward  ..(POD -7)

now will require high nutritional supplimentation....and close observations...fingers are still crossed !!! lets hope for full recovery.....

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CASE: Unusual case^-www.drkeyurbhatt.in*

74 yrs male + DM + HTN + IHD + COPD

with 1 month history of on and off fever...initially treated as Malaria...later as Typhoid..
cont. diarrhoea...c/o distension and abdominal discomfort for 2 days...
rising bilirubin..., constipation..No..nausea/vomiting...

USG : s/o gross peritonitis CBD 7mm, GB partially distended....rest all WNL... TLC: 21,000. Pt Disoriented with electrolyte imbalance...

Suspected Enteric perforation...... and found to have PERFORATED GB with gross (4 liters) biliary peritonitis...No Gall Stones...CBD normal...

? typhoid induced GB perforation...? lower end block / impacted small stone / stricture

Surgery (lavage, Cholecystectomy, drainage) done in Epidural anesthesia in view of multiple risks...and post op patient is doing well...

later develop bile leak...in drain...Suspected Cystic duct stump blown out...USG: repeated : s/o lower end Small 7 mm impected stone...dilated CBD and IHBRD....

Pt underwent ERC & removal of ampulary impected stone and stenting.....
doing well now...

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Superior Mesenteric Artery Syndrome^-www.drkeyurbhatt.in*

Superior mesenteric artery (SMA) syndrome is an uncommon but well recognized clinical entity characterized by compression of the third, or transverse, portion of the duodenum between the aorta and the superior mesenteric artery. 


This results in chronic, intermittent, or acute complete or partial duodenal obstruction.¹ Superior mesenteric artery syndrome was first described in 1861 by Von Rokitansky, who proposed that its cause was obstruction of the third part of the duodenum as a result of arteriomesenteric compression. 


The superior mesenteric artery usually forms an angle of approximately 45° (range, 38-56°) with the abdominal aorta, and the third part of the duodenum crosses caudal to the origin of the superior mesenteric artery, coursing between the superior mesenteric artery and aorta. 


Any factor that sharply narrows the aortomesenteric angle to approximately 6-25° can cause entrapment and compression of the third part of the duodenum as it passes between the superior mesenteric artery and aorta, resulting in superior mesenteric artery syndrome.

In addition, the aortomesenteric distance in superior mesenteric artery syndrome is decreased to 2-8 mm (normal is 10-20 mm).


In a review of the literature, approximately 0.013-0.78% of the findings from upper GI tract barium studies support a diagnosis of superior mesenteric artery syndrome.
surgery:

Surgical intervention is indicated when conservative measures are ineffective, particularly in patients with a long history of progressive weight loss, pronounced duodenal dilatation with stasis, and complicating peptic ulcer disease. A trial of conservative treatment should be instituted for at least 4-6 weeks prior to surgical intervention.

Choice of procedure is  duodenojejunostomy

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