Unusual Presentation of Bouveret Syndrome Resulting in Both Gastric Outlet Obstruction and Small Bowel Obstruction with Perforation.

Our case describes an 83-year-old female who presented with severe abdominal pain, nausea, and bilious emesis of one day's duration. She had an endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and percutaneous transhepatic biliary drainage (PTCD) one year prior for choledocholithiasis with acute cholangitis in her home country, Scotland. Unfortunately, while visiting family in the United States, her PTCD became dislodged, and she developed progressive worsening abdominal pain. Computerized tomography of her abdomen showed pneumobilia, perigastric inflammation, a contracted gallbladder, small bowl inflammation with a likely transition point at the mid-jejunum, and a probable duodenal mass. The patient underwent an exploratory laparotomy with intraoperative findings of choledochoduodenal fistula with coincident gastric and small bowel obstruction (SBO) secondary to three large, mixed gallstones. One 3 cm gallstone was located at the pylorus and two (2.3 and 3 cm) gallstones were isolated in the mid-jejunum, with one of those causing isolated transmural pressure necrosis with subsequent perforation. Bouveret syndrome is a rare cause of gastric outlet obstruction (GOO) that manifests via an acquired cholecystoenteric fistula. Our patient presented with a concomitant GOO and SBO with perforation of the mid-jejunum. Timely diagnosis of Bouveret syndrome is essential, as most causes require emergent surgical intervention.

Improving Blunt Chest Wall Injury Outcomes: Introducing the PIC Score.

BACKGROUND: To improve care for nonintubated blunt chest wall injury patients, our Level I trauma center developed a treatment protocol and a pulmonary evaluation tool named "PIC Protocol" and "PIC Score," emphasizing continual assessment of pain, incentive spirometry, and cough ability. OBJECTIVE: The primary objective was to reduce unplanned intensive care unit admissions for blunt chest wall injury patients using the PIC Protocol and the PIC Score. Additional outcomes included intensive care unit length of stay, ventilator days, length of hospital stay, inhospital mortality, and discharge destination. METHODS: This was a retrospective cohort study comparing outcomes of rib fracture patients treated at our facility 2 years prior to (control group) and 2 years following PIC Protocol use (PIC group). The protocol included admission screening, a power plan order set, the PIC Score patient assessment tool, in-room communication board, and patient education brochure. Outcomes were compared using independent-samples t tests for continuous variables and Pearson's χ2 for categorical variables with α set to p < .05. RESULTS: There were 1,036 patients in the study (control = 501; PIC = 535). Demographics and injury severity were similar between groups. Unanticipated escalations of care for acute pulmonary distress were reduced from 3% (15/501) in the control group to 0.37% (2/535) in the PIC group and were predicted by a preceding fall in the PIC Score of 3 points over the previous 8-hr shift, marking pulmonary decline by an acutely falling PIC Score. CONCLUSIONS: The PIC Protocol and the PIC Score are easy-to-use, cost-effective tools for guiding care of blunt chest wall injury patients.

Splenic trauma from colonoscopy: A case series.

INTRODUCTION: Splenic trauma is quite rare after colonoscopy and can be overlooked as a complication when a patient presents with severe abdominal pain. It can be difficult to diagnose without appropriate imaging, but it should be considered as part of the differential in a patient arriving for evaluation of left upper quadrant abdominal pain. PRESENTATION OF CASE: In this case series, we discuss four patients who presented to our institution with splenic trauma specifically after colonoscopy. These patients were diagnosed with splenic trauma utilizing computed tomography (CT) scans of the abdomen and pelvis. They were all immediately transferred to our surgical intensive care unit (SICU) for close monitoring and serial hemoglobin checks. Two of the four patients had decreasing hemoglobin levels and were monitored until they underwent interventional radiology (IR) angiography and angioembolization. The other two patients had significant transfusion requirements and ultimately went to the operating room for an open splenectomy. All four of these patients did well after their interventions, although one of them required longer hospitalization while on the ventilator secondary to Haemophilus infection. DISCUSSION: This case series recognizes that there is potential for quite severe splenic trauma after colonoscopy. While one of the four patients did have a history of prior splenic trauma, the other three had no history of trauma. CONCLUSION: These cases demonstrate that this complication should be managed similarly to traumatic splenic injury unrelated to colonoscopy, and that non-operative treatment remain a possibility. Certainly, non-operative management requires a SICU and IR capabilities to be successful. If the patient becomes unstable, they should undergo the appropriate operative intervention.

Trauma 2007: a finger on the pulse.

Truma surgery today is facing a number of significant challenges that offer a stimulus for growth and evolution of tl practice. To successfully face these challenges, reexamination of the discipline, the current practice models for its providers, and the definition/scope of the specialty will be necessary. Further development and application of the cute care surgery model may represent the future direction for trauma care practitioners.