Superior mesenteric artery syndrome in a child with acute gastric dilatation with refractory Guillain-Barré syndrome.

Superior Mesenteric Artery Syndrome (SMAS) resulting from proximal partial small bowel obstruction is one of possible causes of acute gastric dilatation (AGD). A child with refractory demyelinating Guillain-Barré syndrome which received 5 times IVIG and consequently 5 times plasmapheresis intubated until 59th day of admission. Because of complicated treatment and cardiopulmonary resuscitation (CPR) nutrition was completely neglected which lead to severe SMAS because of weight loss. Gradual advancements of continuous enteral and parenteral nutrition improved patient's symptoms significantly. Hypophosphatemia complicated the weaning from ventilator which after nutrition therapy resolved and patient extubated. Present case is the first report of pediatric demyelinating GBS suspected to SMAS.

One anastomosis gastric bypass: key technical features, and prevention and management of procedure-specific complications.

INTRODUCTION: One anastomosis gastric bypass (OAGB) is now a recognized mainstream bariatric procedure being adopted by an increasing number of surgeons. The purpose of this review was to present an evidence-based summary of its key technical aspects and prevention and management of its specific complications. EVIDENCE ACQUISITION: We examined PubMed for all published articles on OAGB, including the ones published under one of its various other names. EVIDENCE SYNTHESIS: An ideal OAGB procedure has a long, narrow pouch constructed carefully to avoid going too close to the greater curvature of the stomach especially at the bottom of the pouch and maintains a safe distance from the angle of His. A bilio-pancreatic limb length of 150 cm appears to be safest and a limb length of >200 cm is associated with a significantly increased incidence of protein-calorie malnutrition. We recommend routine closure of Petersen's space to prevent Petersen's hernia and suggest a protocol for micronutrient supplementation. This review also presents evidence-based algorithms for prevention and management of marginal ulcers, protein-calorie malnutrition, and gastroesophageal reflux disease after OAGB. We suggest lifelong supplementation with two multivitamin/mineral supplements (each containing at least 1.0 mg copper and 15 mg zinc) daily, 1.5 mg vitamin B12 orally daily or 3-monthly injection with 1 mg vitamin B12, 120 mg elemental iron daily, 1500 mg elemental calcium daily, and 3000 international units of vitamin D daily. CONCLUSIONS: This review examines key technical steps of OAGB. We also discuss how to prevent and manage its specific complications.

Mouse Gamma Herpesvirus MHV-68 Induces Severe Gastrointestinal (GI) Dilatation in Interferon Gamma Receptor-Deficient Mice (IFNγR-/-) That Is Blocked by Interleukin-10.

Inflammatory bowel disease (IBD) and Clostridium difficile infection cause gastrointestinal (GI) distension and, in severe cases, toxic megacolon with risk of perforation and death. Herpesviruses have been linked to severe GI dilatation. MHV-68 is a model for human gamma herpesvirus infection inducing GI dilatation in interleukin-10 (IL-10)-deficient mice but is benign in wildtype mice. MHV-68 also causes lethal vasculitis and pulmonary hemorrhage in interferon gamma receptor-deficient (IFNγR-/-) mice, but GI dilatation has not been reported. In prior work the Myxomavirus-derived anti-inflammatory serpin, Serp-1, improved survival, reducing vasculitis and pulmonary hemorrhage in MHV-68-infected IFNγR-/- mice with significantly increased IL-10. IL-10 has been investigated as treatment for GI dilatation with variable efficacy. We report here that MHV-68 infection produces severe GI dilatation with inflammation and gut wall degradation in 28% of INFγR-/- mice. Macrophage invasion and smooth muscle degradation were accompanied by decreased concentrations of T helper (Th2), B, monocyte, and dendritic cells. Plasma and spleen IL-10 were significantly reduced in mice with GI dilatation, while interleukin-1 beta (IL-1ß), IL-6, tumor necrosis factor alpha (TNFα) and INFγ increased. Treatment of gamma herpesvirus-infected mice with exogenous IL-10 prevents severe GI inflammation and dilatation, suggesting benefit for herpesvirus-induced dilatation.

Massive gastric dilatation leading to acute respiratory distress 1 year after a Nissen fundoplication.

Acute massive gastric dilatation (AMGD) is a recognised complication after Nissen fundoplication.1 A 63-year-old man recently presented to our emergency department in acute respiratory distress, acute abdominal pain and distension, having had an elective umbilical port incisional hernia repair a day prior. In the year preceding his presentation, the patient had undergone a laparoscopic paraoesophageal hiatus hernia repair and excision of sac, posterior cruropexy, dual mesh reinforcement of repair and 360° fundoplication, as a day case. In between these two events, the patient was asymptomatic, and had a free diet with no further medical or surgical intervention. We hereby present successful management and discuss implications of this exceptional yet potentially life-threatening complication.

Case report of gastric distension due to superior mesenteric artery syndrome mimicking hollow viscus perforation: Considerations in critical care ultrasound.

RATIONALE: Critical care ultrasound identifies the signs of free intraperitoneal air and echogenic free fluid always indicates hollow viscus perforation (HVP) and needs immediate surgical interventions. However, in rare cases, these classic signs may also mislead proper clinical decisions. We report perforated viscus associated large peritoneal effusion with initial critical care ultrasound findings, whereas computed tomography (CT) examination confirmed a giant stomach due to superior mesenteric artery syndrome (SMAS). PATIENT CONCERNS: A 70-year-old man was admitted to our emergency department with a complaint of recurrent vomiting with coffee ground emesis for 15 hours and worsen with hypotension for 6 hours. During gastric tube placement, the sudden cardiac arrest occurred. With 22 minutes resuscitation, sinus rhythm was restored. DIAGNOSES: Quick ultrasound screen showed large echogenic fluid distributed in the whole abdomen. Diagnostic paracentesis collected "unclotted blood" and combined with a past history of duodenal ulcer, HVP was highly suspected. However, surgical intervention was not performed immediately as unstable vital signs and unfavorable coma states. After adequate resuscitation in intensive care unit, the patient was transferred to perform enhanced CT. Surprisingly, there was no evidence of HVP. Instead, CT showed a giant stomach possibly explained by SMAS. INTERVENTIONS: Continuous gastric decompression was performed and 3100 mL coffee ground content was drainage within 24 hours of admission. OUTCOMES: Abdominal distension was significantly relieved with improved vital signs. However, as the poor neurological outcome, family members abandon further treatment, and the patient died. LESSONS: SMAS is a rare disorder, characterized by small bowel obstruction and severe gastric distension. Nasogastric tube insertion should be aware to protect airway against aspiration. Caution should be utilized to avoid over interpretation of ultrasonography findings on this condition.

Acute gastric dilatation in a patient with lupus nephritis: An uncommon presentation of lupus mesenteric vasculitis.

Abdominal symptoms are common in patients with lupus nephritis and are often attributed to drugs or uremia per se. Lupus mesenteric vasculitis (LMV) or lupus enteritis is a rare entity reported in patients with active systemic lupus erythematosus. It usually occurs in patients with a long-standing history of lupus with high disease activity. Usually, small bowel is predominantly affected. The stomach and rectum are spared in view of significant collateral circulation. Here, we describe an 18-year-old boy who presented with nephrotic syndrome without any extrarenal features of lupus. On subsequent evaluation, he was found to have active lupus nephritis. He developed acute gastric dilatation secondary to extensive LMV. Imaging showed an extensive involvement of gastrointestinal tract from the stomach to the sigmoid colon, sparing the rectum. To the best of our knowledge, this is the first report of LMV presenting as acute gastric dilatation.

Intentional tracheoesophageal fistula cannulation for gastric decompression in type C esophageal atresia.

We describe a nonsurgical technique for managing gastric distention in infants with type C esophageal atresia, involving intubating the trachea with an umbilical catheter and entering the stomach through the fistula as soon as a flexible bronchoscope found its wide-open orifice. This technique might have a special role when gastric distention precedes other commonly used preventive measures.

Food engorgement in 35 dogs (2009-2013) compared with 36 dogs with gastric dilation and volvulus.

The clinical features and management of food engorgement (FE) in dogs have not been previously described. This retrospective observational study describes characteristics and outcome of 35 dogs with FE, and compares features on presentation to 36 dogs with gastric dilation and volvulus (GDV). Cases were retrospectively reviewed for history, clinical findings and outcome. Gastric distension was measured by caudal gastric margin (CGM), level with lumbar vertebrae, on a lateral abdominal radiograph. Frequent characteristics of dogs with FE included tachycardia, tachypnoea, hyperproteinaemia, increased base excess (BE), mild hypernatraemia and hyperlactataemia. There was overlap in CGM between dogs with GDV (CGM range L3 to >L6) and dogs with FE (CGM range

Two cases of acute gastric dilation after radiofrequency catheter ablation for supraventricular arrhythmia.

We describe our experience with two cases of acute gastric dilation after radiofrequency catheter ablation (RFCA) for supraventricular arrhythmia. After the RFCA procedure, patients experienced epigastric pain, abdominal distension, and vomiting. Computed tomography showed marked dilation of their stomachs, but without apparent obstruction of the gastric antrum or the duodenum. Esophagogastroduodenoscopy and upper gastrointestinal series revealed significant gastroparesis. We considered that gastric hypomotility had been induced by vagus nerve injury after RFCA. Peristaltic stimulants effectively improved the patients' symptoms by improving gastric motility. There have been few reports of acute gastric dilation after RFCA in Japan to date, but the possibility of encountering this condition is expected to increase in parallel with the recent increased use of RFCA. Therefore, gastroenterologists should be alert to this rare complication.

Gas and Bloating-Controlling Emissions: A Case-Based Review for the Primary Care Provider.

The evaluation of the patient with gas and bloating can be complex and the treatment extremely challenging. In this article, a simplified approach to the history and relevant physical examination is presented and applied in a case-oriented manner, suitable for application in the primary care setting.

[Effects of acupuncture at "Zusanli" (ST 36) on sensitive neurons of gastric distention in LHA-FN circuit in rats].

OBJECTIVE: To observe the regulation effects of acupuncture at "Zusanli" (ST 36) on sensitive neurons of gastric distention (GD) in lateral hypothalamus area (LHA) and fastigial nuclear (FN) circuit, and to explore the central mechanism of acupuncture for gastric function. METHODS: A total of 101 rats were randomly assigned into a LHA group (50 rats) and a FN group (51 rats). Gastric distension surgery was performed in all the rats. According to the stereotaxic atlas of rat brain, the LHA and FN were located, followed by craniotomy. The endocranium was removed to exposure brain tissue, and warm paraffin oil was used to prevent desiccation. The electrical activities of neurons were probed by glass microelectrode to perform extracellular recording. The electrical activities of GD sensitive neurons in LHA were observed in LHA group, while those in FN were observed in FN group. One min after the electrical signal of neurons was recorded, acupuncture was given at left "Zusanli" (ST 36) with mild reinforcing and attenuating technique, 120~180 times/min for 1 min. The effects of acupuncture at "Zusanli" (ST 36) on spontaneous discharge of GD sensitive neurons in LHA and FN were observed. RESULTS: (1) Totally 54 LHA neurons of spontaneous discharge in LHA group and 85 FN neurons in FN group were recorded. GD-excitatory (GD-E) neurons were mainly in the LHA group (46.3%) and GD-non-response (GD-N) neurons were mainly in the FN group (54.12%). The average discharge frequency of GD-N neurons was (39.03±14.91) spikes/s, that of GD-E neurons was (19.67±12.08) spikes/s, and that of GD-inhibitory (GD-I) neurons was (28.76±7.26) spikes/s, which were statistically different from those before GD (all P<0.01). (2) In LHA group, acupuncture excited the activity of GD-E neurons, and inhibited the activity of GD-I neurons (P<0.05); in FN group, acupuncture excited the activity of GD-I neurons, but showed no effect on GD-E neurons (P<0.01). CONCLUSIONS: The signal of GD and acupuncture could converge in LHA and FN; acupuncture presented different regulation effects on identical type of GD-sensitive neurons in different nuclear groups; LHA-FN circuit might participate in central integration mechanism of acupuncture on gastric function.

Gastrojejunostomy for pyloric stenosis after acute gastric dilatation due to overeating.

A 34-year-old woman presented at our hospital with abdominal distention due to overeating. Acute gastric dilatation was diagnosed. The patient was hospitalized, and nasogastric decompression was initiated. On hospitalization day 3, she developed shock, and her respiratory state deteriorated, requiring intubation and mechanical ventilation. Nasogastric decompression contributed to the improvement in her clinical condition. She was discharged 3 mo after admission. During outpatient follow-up, her dietary intake decreased, and her body weight gradually decreased by 14 kg. An upper gastrointestinal series and endoscopy revealed pyloric stenosis; therefore, we performed gastrojejunostomy 18 mo after her initial admission. The patient was discharged from the hospital with no postoperative complications. Gastric necrosis and perforation due to overeating-induced gastric dilatation are life-threatening conditions. Surgical intervention may be required if delayed pyloric stenosis occurs after conservative treatment. We report a case of pyloric stenosis due to overeating-induced gastric dilatation treated by gastrojejunostomy 18 mo after the initial presentation.

Medical treatment of 145 cases of gastric dilatation in rabbits.

Gastric dilatation is an acute and life-threatening condition in pet rabbits commonly caused by an intestinal obstruction with pellets of compressed hair. Surgery is normally considered to be the treatment of choice to alleviate the obstruction. However, for various reasons such as restrictions by the owner, a high anaesthetic risk due to the critical condition of the patient or concurrent diseases, surgical treatment may be impossible. In a three-year period, 145 cases of gastric dilatation were treated medically with a combination of metoclopramide, metamizole, balanced fluid electrolyte solution with glucose and syringe feeding. No gender or breed predisposition could be noted. Four animals were euthanased, three of them directly after diagnosis. Eleven animals died, eight of them on the day of presentation. The medical treatment was successful in 130 cases (89 per cent) with a mean treatment time of three days. The animals were released from hospital when eating and defecating normally. Although the use of medical treatment of gastric dilatation has to be thoroughly considered, especially regarding the severity of obstruction, the painfulness and the animal's welfare, the good survival rate observed with these animals makes it a good option for all cases where surgical treatment is contraindicated.

Nonsurgical management of luminal dilatation after laparoscopic adjustable gastric banding.

BACKGROUND: Proximal luminal dilatation (PLD) is one of the most significant challenges following laparoscopic adjustable gastric banding (LAGB). If PLD is identified at an early stage, there is potential to avoid reoperation or irreversible change by implementing nonsurgical measures. The success of these strategies is unknown. The aim of this study was to determine the outcome of how often PLD can be successfully treated nonsurgically. METHODS: The records of patients who underwent primary LAGB insertion by a single surgeon from January 2005 to December 2006 were reviewed. Study participants were all patients who had subsequently undergone a postoperative liquid contrast swallow demonstrating a PLD. The severity of PLD, subsequent management, and outcomes were recorded and assessed. RESULTS: There were 354 patients who underwent a primary LAGB insertion during the study period. Seventy-eight patients were found to have varying degrees of PLD and had an attempt at nonsurgical management. Thirty-four of these patients (43.6 %) were successfully managed nonsurgically at a mean follow-up of 2.8 years (33.2 months, CL ± 3.2). The success with nonsurgical management was lower if the symmetrical pouch dilatation was more severe or gastric prolapse was seen at presentation, and if no improvement in liquid contrast swallow was seen. CONCLUSIONS: PLD can often be successfully managed with nonsurgical measures, maintaining good weight loss in the intermediate term. Patients with more significant dilatation are more likely to require revisional surgery. Early recognition may have a role in preventing surgery or more severe abnormalities.