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Bariatric surgery is becoming an accepted method for weight reduction. Biliopancreatic diversion is reserved for high initial BMI. With the increasing number of these procedures, the reports of complications become more important and prepare a wider range of specialties to deal with them. We report a 62-year-old woman who developed a volvulus of the biliopancreatic loop after a biliary diversion operation with a sleeve gastrectomy and antro-ileal anastomosis. Symptoms of biliopancreatic loop obstruction are rather vague, presenting with atypical abdominal pain, nausea, sometimes vomiting, preserved bowel motility, stool, and gas passage and normal upper GI X-ray. Due to the patient's prompt reaction and straight referral to a bariatric surgeon, freeing of the loop was enough to maintain its viability. The patient's further recovery and follow-up were uneventful. With this case, we stress the importance of an expert in such cases and a need to consider familiarizing doctors with these patients and with the peculiarities of their treatment.
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PMID:Prompt treatment of intestinal obstruction after biliopancreatic diversion can save the intestinal loop. 1844 19

Bouveret's Syndrome is obstruction of the duodenum secondary to an impacted gallstone, usually without the presence of pneumobilia With the steadily increasing lie expectancy, greater number of these cases are being seen. Gallstones enter the gastrointestinal tract following fistula formation between the gallbladder and an adjacent hollow viscus and may cause obstruction at any point along the intestinal tract. Duodenal obstruction is the least common and represents only a very small percentage of cases. The presenting signs of nausea vomiting, abdominal cramping, and the absence of abdominal distension should alert the clinician to pathology in the proximal small bowel. The purpose of this report is to heighten the awareness of the primary care physician, emergency room doctors and surgeons to this diagnosis in elderly patients so that it can be included in the differential with the usual cases of gastric outlet obstruction--including ulcer disease, neoplasms, gastric volvulus, and other enteroliths, such as bezoars. Early diagnosis is critical, as these cases require urgent surgical intervention. Early resuscitation. Diagnosis, and treatment are essential for a successful outcome.
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PMID:[Bouveret' syndrome or secondary duodenal obstruction caused by gallstones. Case report]. 1869 20

Volvulus of the gastrointestinal tract, a clinically relevant cause of acute or recurring abdominal pain in adults, remains a diagnostic dilemma for radiologists in a large number of cases. The clinical symptoms associated with volvulus are often nonspecific and include pain and nausea with vomiting. Yet referring clinicians often rely on radiologists to make the diagnosis; volvulus is rarely diagnosed clinically. Radiography, fluoroscopy, and computed tomography are the imaging methods most often used for this purpose. Prompt diagnosis is critical to avoid life-threatening complications such as bowel ischemia and infarction. Thus, it is useful for radiologists to be familiar with the various appearances of volvulus throughout the gastrointestinal tract.
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PMID:Volvulus of the gastrointestinal tract: appearances at multimodality imaging. 1975 96

Acute esophageal necrosis (AEN), commonly referred to as "black esophagus", is a rare clinical entity arising from a combination of ischemic insult seen in hemodynamic compromise and low-flow states, corrosive injury from gastric contents in the setting of esophago-gastroparesis and gastric outlet obstruction, and decreased function of mucosal barrier systems and reparative mechanisms present in malnourished and debilitated physical states. AEN may arise in the setting of multiorgan dysfunction, hypoperfusion, vasculopathy, sepsis, diabetic ketoacidosis, alcohol intoxication, gastric volvulus, traumatic transection of the thoracic aorta, thromboembolic phenomena, and malignancy. Clinical presentation is remarkable for upper gastrointestinal bleeding. Notable symptoms may include epigastric/abdominal pain, vomiting, dysphagia, fever, nausea, and syncope. Associated laboratory findings may reflect anemia and leukocytosis. The hallmark of this syndrome is the development of diffuse circumferential black mucosal discoloration in the distal esophagus that may extend proximally to involve variable length of the organ. Classic "black esophagus" abruptly stops at the gastroesophageal junction. Biopsy is recommended but not required for the diagnosis. Histologically, necrotic debris, absence of viable squamous epithelium, and necrosis of esophageal mucosa, with possible involvement of submucosa and muscularis propria, are present. Classification of the disease spectrum is best described by a staging system. Treatment is directed at correcting coexisting clinical conditions, restoring hemodynamic stability, nil-per-os restriction, supportive red blood cell transfusion, and intravenous acid suppression with proton pump inhibitors. Complications include perforation with mediastinal infection/abscess, esophageal stricture and stenosis, superinfection, and death. A high mortality of 32% seen in the setting of AEN syndrome is usually related to the underlying medical co-morbidities and diseases.
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PMID:Black esophagus: acute esophageal necrosis syndrome. 2061 76

A 3-year-old boy presented at the emergency room with abdominal pain, nausea and non-bilious vomiting. Physical examination revealed moderate symptoms of dehydration, a tender and slightly extended but soft abdomen and active peristalsis. With the working diagnosis of viral gastroenteritis the boy was admitted to the hospital for rehydration therapy by nasogastric tube. After a few days an abdominal X-ray was taken because of bilious vomiting and persistent absence of defecation. Connected foreign bodies were seen in the small intestine. These appeared to be 3 magnetic toy parts. Laparotomy showed that all symptoms were due to a volvulus of the small intestine around a fistula caused by entrapment of the intestinal wall between attracted magnets. Magnetic construction toys can be bought in toy stores in the Netherlands. Vigilance should be exercised with magnetic toys, because ingestion of multiple magnets can cause potentially life-threatening bowel complications.
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PMID:[Serious gastrointestinal complications due to accidental ingestion of magnetic toy parts]. 2069 28

An eighteen-month-old boy who had undergone a Ladd's procedure for malrotation in the newborn period presented with acute onset of nausea, vomiting, rectal bleeding, and confusion. Laparotomy revealed midgut volvulus, mesenteric lymphadenopathy and massive chylous ascites. Recurrent midgut volvulus following Ladd's procedure is extremely rare but should be borne in mind in cases of persistent or recurrent gastrointestinal symptoms. Timely surgery is necessary to avoid intestinal gangrene and decrease morbidity and mortality related to consequences of midgut volvulus.
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PMID:A Rare but Serious Complication of Ladd's Procedure: Recurrent Midgut Volvulus. 2148 58

The authors describe a case of gastric volvulus, which is a rare cause of gastric outlet obstruction. An 85-year-old man presented with nausea, vomiting, and epigastric pain. Admission abdominal radiograph demonstrated a grossly distended stomach with air-fluid levels. Multiple attempts at nasogastric tube placement failed. Endoscopy revealed a fluid-filled, tortuous stomach with a paraesophageal hernia, and the operator was unable to locate or pass the scope through the pylorus. Traditionally Borchardt's triad is believed to be diagnostic for acute gastric volvulus and consists of unproductive retching, epigastric pain and distention, and the inability to pass a nasogastric tube. The authors propose that the following features on endoscopy are highly suggestive of the most common type of volvulus (organoaxial): tortuous stomach, paraesophageal hernia, and inability to locate or pass the scope through the pylorus.
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PMID:Gastric volvulus, Borchardt's Triad, and Endoscopy: A Rare Twist. 2178 7

An 48-year old woman presented at the emergency room with epigastric pain and nausea. 6 months earlier she had a distended ascending colon, which resolved quickly after conservative treatment with nasogastric tube. Now she had similar complaints. A plain abdominal radiograph was not conclusive; barium enema examination demonstrated a cecal volvulus. Patient required right hemicolectomy. She recovered uneventfully.
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PMID:[A woman with nausea and epigastric pain]. 2255 43

Visceral myopathy is a rare chronic disease affecting the peristalsis of the bowel causing intermittent pseudoobstruction. We report an atypical case of an eighty-nine-year-old woman with no prior history of abdominal illness who was admitted to our hospital with 2 days of increasing nausea, abdominal distension, and abdominal pain. On arrival at the hospital, she was critically ill. Abdominal X-ray showed distended loops of the colon and liquid levels resembling colonic obstruction. A subsequent abdominal CT scan confirmed the colonic obstruction. A suspicion of sigmoid volvulus was raised, that is why a barium enema was performed but no lower colonic obstruction could be confirmed. Acute laparotomy showed perforated cecum without intestinal obstruction. Postoperatively, the patient became septic which was fatal for the patient. Pathology gave the diagnosis visceral myopathy. It is very difficult to make the diagnosis clinically and radiologically since visceral myopathy mimics other more common gastrointestinal diseases. It is important to consider visceral myopathy as a possible diagnosis in cases with recurrent episodes of abdominal pain, vomiting, and abdominal distension, but without actual intestinal obstruction.
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PMID:Acute abdomen and perforated bowel with a rare pathology: nonfamilial visceral myopathy. 2260 88

Acute sigmoid volvulus is typically caused by an excessively mobile and redundant segment of colon with a stretched mesenteric pedicle. When this segment twists on its pedicle, the result can be obstruction, ischemia and perforation. A healthy, 18-year-old Caucasian woman presented to the emergency department complaining of cramping abdominal pain, distention, constipation and obstipation for the last 72 h, accompanied by nausea, vomiting and abdominal tenderness. The patient had tympanitic percussion tones and no bowel sounds. She was diagnosed with acute sigmoid volvulus. Although urgent resective surgery seems to be the appropriate treatment for those who present with acute abdominal pain, intestinal perforation or ischemic necrosis of the intestinal mucosa, the first therapeutic choice for clinically stable patients in good general condition is considered, by many institutions, to be endoscopic decompression. Controversy exists on the decision of the time, the type of definitive treatment, the strategy and the most appropriate surgical technique, especially for teenagers for whom sigmoid resection can be avoided.
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PMID:Management of sigmoid volvulus avoiding sigmoid resection. 2275 89


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