Gastric dilatation and intestinal obstruction mimicking acute coronary syndrome with dynamic electrocardiographic changes.

BACKGROUND: ST elevation myocardial infarction is a medical emergency and the electrocardiogram is a part of the mainstay in the initial diagnosis. A variety of non-cardiac conditions have been known to mimic the electrocardiographic changes seen in acute coronary syndrome. We present a patient presenting with acute partial intestinal obstruction causing gastric distension and intestinal dilatation who also had dynamic electrocardiographic changes, mimicking anterior ST elevation myocardial infarction. Only very few cases of gastric distention and intestinal dilatation leading to acute ST segment elevation in electrocardiogram are reported so far in literature. CASE PRESENTATION: A fifty-six-year-old Sri Lankan male, without any modifiable risk factors for ischemic heart disease presented with acute onset nausea, vomiting, sweating, abdominal discomfort and fullness without any chest pain. On examination, he had a pulse rate of 50 beats per minute and his blood pressure was 110/50 mmHg. His abdomen was distended and the liver dullness was not detectable. Subsequent ECG showed > 2 mm ST elevations with T inversions in chest leads V1 to V3, J point elevation in leads L 11, L 111, aVF and T inversion in leads L 1 and aVL. Cardiac biomarkers were normal and 2D echo showed normal left ventricular function without any regional wall motion abnormalities. Abdominal X-ray showed a distended stomach, dilated ascending and descending colon with absent rectal air. Electrocardiographic changes reverted back to normal with the resolution of bowel obstruction. CONCLUSION: The mechanism of ECG changes in such a case like this is yet to be elucidated, but can be postulated to happen due to change in the position of the heart in the thoracic cavity causing change in the cardiac axis. This case emphasizes the importance of a proper history and highlights the value of auxiliary investigations such as cardiac biomarkers and echocardiogram in the diagnosis of acute coronary syndrome in a confusing situation such as this. This also illustrates the importance of early recognition of other noncardiac causes like acute gastric distention as being responsible for dynamic ECG changes. This will obviate a myriad of unnecessary investigations, interventions, costly management strategies and patient anxiety.

Life-threatening acute gastric dilatation with aorta compression in a 3-year-old child.

We report a fatal case of acute gastric dilatation in a 3-year old boy who presented with severe abdominal pain and massive gastric distension in the emergency room. On physical examination the patient was in shock due to acute abdomen and lower limb ischemia. Initial laboratory findings showed multi-organ failure with acute renal failure and pancreatitis. Abdominal computed tomography (CT) showed marked dilatation of the stomach resulting in compression of the abdominal aorta. The left kidney, spleen and pancreas were not visible on CT due to the necrotic changes. The patient was quickly stabilized by initial volume resuscitation, but suddenly deteriorated immediately after gastric decompression via nasogastric tube, and died from multi-organ failure 3 h after initial presentation.

Gastric dilatation and volvulus in a red panda (Ailurus fulgens).

OBJECTIVE: To describe the successful management of gastric dilatation and volvulus (GDV) in a red panda. STUDY DESIGN: Clinical report. ANIMALS: Red panda diagnosed with GDV. RESULTS: A 12-year-old male red panda (Ailurus fulgens) was evaluated for acute onset inappetence, staggering, collapse, and tachypnea. Gastric dilatation and volvulus (GDV) was diagnosed by radiography, abdominal ultrasonography, and exploratory celiotomy. Torsion of the stomach was corrected and an incisional gastropexy performed to prevent recurrence. No organs were devitalized, no other abnormalities detected, and the red panda recovered fully within 72 hours. CONCLUSIONS: GDV should be considered as a differential diagnosis for red pandas presenting with acute onset of unspecific signs such as collapse, inappetence, and abdominal distension. GDV in red pandas can be diagnosed and successfully treated as described in dogs.

Unusual case of gastroparesis leading to severe gastromegaly with demyelinating disease as a rare cause.

INTRODUCTION: Gastroparesis is an entity of symptomatic abnormal gastric emptying, with diabetes mellitus, postsurgical and idiopathic etiologies accounting for majority of the cases. CASE REPORT: We report the case of a young African American female, who presented with abdominal discomfort, inability to tolerate a regular diet and intermittent episodes of numbness, tingling and cramps in her extremities. CT scan of the abdomen and pelvis showed a massively distended stomach, compressing the intestines and liver. A gastric emptying study revealing markedly worsened gastroparesis. Severe gastroparesis causing massive gastromegaly secondary to multiple sclerosis was diagnosed. CONCLUSION: This case illustrates severe gastromegaly that is rarely seen to this extent and identifies multiple sclerosis (MS) as a rare cause of gastroparesis. MS should be considered in the differential diagnosis of gastroparesis in appropriate clinical settings.

Gastric rupture with necrosis following acute gastric dilatation: report of a case.

Gastric rupture with necrosis following acute gastric dilatation (AGD) is a rare and potentially fatal event; usually seen in patients with eating disorders such as anorexia nervosa or bulimia. A 12-year-old lean boy with no remarkable medical history was brought to our Emergency Department suffering acute abdominal symptoms. Emergency laparotomy revealed massive gastric dilatation and partial necrosis, with rupture of the anterior wall of the fundus of the stomach. We performed partial gastrectomy and the patient recovered uneventfully. We report this case to demonstrate that AGD and subsequent gastric rupture can occur in patients without any underlying disorders and that just a low body mass index is a risk factor for this potentially fatal condition.

Gastric distension.

CASE STUDY: A woman, 82 years of age, presented to the emergency department with an 8 day history of worsening generalised abdominal pain, nonfaecal emesis and abdominal distension associated with a background history of 20 kg weight loss over the past few months.

Gastric dilatation-volvulus in a guinea pig (Cavia porcellus).

A 3-year-old, intact female guinea pig (Cavia porcellus) was presented for anorexia and abdominal distention of 24 hours' duration. Radiographs revealed a severely distended stomach, suggestive of severe gastric dilatation or gastric dilatation-volvulus (GDV). Exploratory surgery was recommended, but the owners elected euthanasia. On necropsy, the guinea pig was found to have GDV. No underlying conditions were identified that could have predisposed this guinea pig to the development of GDV.

Gastric insufflation during cardiopulmonary resuscitation: A study in human cadavers.

INTRODUCTION: Bag-valve-mask ventilation is the first-line ventilation method during cardiopulmonary resuscitation (CPR). Risks include excessive volume delivery and gastric insufflation, the latter increasing the risk of pneumonia. The efficacy of ventilation can also be reduced by airway closure. We hypothesized that continuous chest compression (CC) could limit the risk of gastric insufflation compared to the recommended 30:2 interrupted CC strategy. This experimental study was performed in human "Thiel" cadavers to assess the respective impact of discontinuous vs. continuous chest compressions on gastric insufflation and ventilation during CPR. METHODS: The 30:2 interrupted CC technique was compared to continuous CC in 5 non-intubated cadavers over a 6 min-period. Flow and Airway Pressure were measured at the mask. A percutaneous gastrostomy allowed measuring the cumulative gastric insufflated volume. Two additional cadavers were equipped with esophageal and gastric catheters instead of the gastrostomy. RESULTS: For the 7 cadavers studied (4 women) median age of death was 79 [74-84] years. After 6 min of CPR, the cumulative gastric insufflation measured in 5 cadavers was markedly reduced during continuous CC compared to the interrupted CC strategy: (1.0 [0.8-4.1] vs. 5.9 [4.0-5.6] L; p < 0.05) while expired minute ventilation was slightly higher during continuous than interrupted CC (1.9 [1.4-2.8] vs. 1.6 [1.1-2.7] L/min; P < 0.05). In 2 additional cadavers, the progressive rise in baseline gastric pressure was lower during continuous CC than interrupted CC (1 and 2 cmH2O vs. 12 and 5.8 cmH2O). CONCLUSION: Continuous CC significantly reduces the volume of gas insufflated in the stomach compared to the recommended 30:2 interrupted CC strategy. Ventilation actually delivered to the lung is also slightly increased by the strategy.

Acute massive gastric dilatation as a result of closed-loop obstruction of stomach: an unusual and rare phenomenon.

Acute massive gastric dilatation (AMGD) is a rare event which is usually underdiagnosed. It can occur due to multiple etiologies, including medical and surgical, or as a postoperative complication. We report a rare case of AMGD as a result of closed-loop obstruction of the stomach following feeding jejunostomy in a patient with carcinoma oesophagus. A high index of suspicion, early diagnosis and prompt management is the key to the successful treatment. To the best of our knowledge, this is the second case report of a closed-loop obstruction of the stomach leading to AMGD in published literature.

Positive glucose breath testing is more prevalent in patients with IBS-like symptoms compared with controls of similar age and gender distribution.

BACKGROUND: Small intestinal bacterial overgrowth (SIBO) may mimic a functional disorder such as irritable bowel syndrome (IBS) or functional bloating (FB). In this study, we aimed to assess the utility of glucose breath test (GBT) in patients with the above conditions. METHODS: This study included 200 consecutive patients (130 with IBS and 70 with FB on the basis of Rome III criteria) and 70 controls with similar age and sex distribution. Patients and controls underwent 50 g GBT and a H2 peak of > or = 12 ppm was considered diagnostic of SIBO. Positive patients received rifaximin of 1200mg/day for 10 days and underwent a second GBT 1 month after the end of treatment. A symptom questionnaire was completed before and after therapy. RESULTS: GBT resulted to be altered in 21 out of 130 IBS patients and in 2 out of 70 FB patients with a significant difference of the former group compared with controls (3 out of 70, P=0.0137). Most IBS patients with a positive GBT complained of diarrhea. GBT showed an increased methane excretion in 26% of patients, who were equally distributed among different bowel pattern subgroups. Previous abdominal surgery was more frequently seen in GBT-positive patients (P=0.008). After antibiotic treatment, eradication of SIBO was achieved in 70% of patients, with a significant improvement of symptoms in eradicated patients compared with the not eradicated ones (P<0.001). CONCLUSIONS: GBT is useful to identify a subgroup of IBS-like patients, whose symptoms are owing to SIBO. Normalization of GBT after antibiotic therapy is associated with a significant improvement of symptoms. GBT does not offer any advantage in FB patients.

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.

[Gastric dilatation-volvulus syndrome in guinea pigs (Cavia porcellus)]. / Magendrehung (Dilatatio et Torsio ventriculi) beim Meerschweinchen (Cavia porcellus).

AIM: The aim of this study was to present an overview of the gastric dilatation-volvulus syndrome in guinea pigs. MATERIAL AND METHODS: Four cases of gastric dilatation-volvulus syndrome in guinea pigs were evaluated. Its clinical presentation, diagnostic options, therapeutical approach and possible alternatives thereof were discussed. Furthermore, risk factors for the disease as well as pathophysiology and etiology were discussed and compared to the situation in other species. RESULTS: The presented cases indicate that in addition to anamnesis and clinical examination, radiography is the means of choice to diagnose a gastric dilatation-volvulus syndrome in guinea pigs. All four patients underwent surgery. One animal was euthanized during surgery, the other three guinea pigs died postoperatively. CONCLUSION AND CLINICAL RELEVANCE: Gastric dilatation-volvulus syndrome in guinea pigs is considered to be an emergency and, therefore, immediate stabilization is necessary, as well as surgery in almost all cases. The prognosis of this disease is guarded to poor.

Laparoscopic gastric rebanding for slippage with pouch dilation: results on 29 consecutive patients.

BACKGROUND: Laparoscopic adjustable gastric banding (LAGB) slippage with pouch dilation is one the most serious long-term complications and requires reoperation in most cases. It is still controversial whether banding should be offered again or a different procedure should be chosen. We report the results of synchronous de-rebanding on a prospective series of patients treated at our institution for slippage with pouch dilation. METHODS: From January 2000 to May 2007, 29 consecutive patients underwent laparoscopic de-rebanding for slippage with pouch dilation. The mean age at primary operation was 38.9 +/- 8.2 years and the mean BMI was 46.4 +/- 8 kg/m(2). Twenty-eight had previous LAGB, while one had previous open gastric banding, the perigastric technique being used at that time. All the redo procedures were successfully carried out under laparoscopy, via the pars flaccida technique, and all the patients were followed-up according to the usual schedule. RESULTS: The mean time from the original LAGB was 45.3 +/- 30.3 months, and the mean follow-up after rebanding was 26.9 +/- 20.6 months. At rebanding, the mean BMI was 34.3 +/- 7.6, percent excess weight loss (%EWL) 54.5 +/- 31, and percent excess BMI loss (%EBL) 58.3 +/- 33, respectively. After 1 year, BMI was 36.3 +/- 7.9, %EWL 40.8 +/- 30.5, and %EBL 43.9 +/- 32.7, respectively. After 2 years, BMI was 37.13 +/- 7.4, %EWL 36.9 +/- 29.4, and %EBL 39.6 +/- 31.6, respectively, and after 3 years, BMI was 33.5 +/- 5.6, %EWL 51.9 +/- 24.3, and %EBL 55.7 +/- 25.7, respectively. One patient had re-rebanding after 6 months for a new slippage, two had band removal with refusal to switch to another procedure, one had biliopancreatic diversion for slippage recurrence, and one underwent sleeve gastrectomy for insufficient weight loss after 6 months. CONCLUSIONS: Although this is a limited series, our results show that good outcomes can be expected after rebanding in properly assessed patients with slippage and pouch dilation. Larger series and longer follow-up are needed to confirm these findings.

Symmetrical pouch dilatation after laparoscopic adjustable gastric banding: incidence and management.

BACKGROUND: Laparoscopic adjustable gastric banding (LAGB) has commonly been complicated by the problem of band slippage or prolapse. Since popularization of the pars flaccida approach and improved anterior fixation, it is our impression that the problem of symmetrical dilatation of the proximal gastric pouch has become more important. METHODS: We have reviewed the results of a series of 425 LAGB all performed by the pars flaccida approach from June 2003 to October 2007 to analyze the incidence and implications of this new pattern. RESULTS: There were no posterior prolapses, 2 anterior prolapses, and 17 cases of symmetrical pouch dilatation (SPD) (revision rate 4.4%). Teenage patients had a 22% revision rate for SPD. All revisions were completed laparoscopically with no mortality, no significant complications, and a median hospital stay of 1 day. The median weight loss following revisional surgery was not significantly different from the background cohort. CONCLUSION: SPD is the most common reason for revision of LAGB in this series. We postulate that SPD is caused by excessive pressure in the proximal gastric pouch. This may be generated either by eating too quickly or too large a volume or excessive tightening of the band. The radial forces in the pouch may ultimately cause pressure on the phrenoesophageal ligament and a secondary hiatal hernia.

Gastric necrosis complicating lately a Nissen fundoplication. Report of a case.

BACKGROUND: Gastric necrosis after Nissen fundoplication is a rare and life-threatening complication described in paediatric surgery and in some experimental models. Prompt diagnosis and appropriate therapy of acute gastric dilatation is mandatory to avoid potentially fatal gastric necrosis. CASE REPORT: This case report is the first one to describe a gastric necrosis in an adult as a late and very severe complication after Nissen fundoplication. Gastric dilatation and subsequent necrosis occurred 14 years after Nissen fundoplication because of small bowel obstruction based on adhesions. CONCLUSION: Early diagnosis and treatment of gastric dilatation after Nissen fundoplication are essential to prevent from severe secondary complications but can be difficult to establish because of atypical symptoms.