Acute mesenteric ischaemia: A case of expedited diagnosis and management using point-of-care ultrasound.

INTRODUCTION: The term acute abdomen refers to a clinical syndrome of sudden onset, severe abdominal pain. The differential diagnosis for this presentation is broad, but most cases require emergent medical or surgical management. Especially in cases of ischaemic bowel, time to diagnosis can mean the difference between survival and death. As a result, mortality remains high in resource-limited settings. CASE REPORT: We describe the case of a 28-year-old male who presented to an urban Ethiopian emergency centre with three days of vomiting, bloody diarrhoea, and abdominal pain. He collapsed in triage with weak pulses and an undetectable blood pressure. Point-of-care ultrasound revealed a hyperechoic, mobile mass in the left ventricle of the heart. Small bowel dilation and thickening was visualised throughout the abdomen. Mesenteric ischaemia was rapidly identified as the working diagnosis, prompting early surgical consultation and aggressive, goal-directed resuscitation. DISCUSSION: Short of elucidating a definitive diagnosis, ultrasound narrowed the focus of an undifferentiated presentation and supported mobilisation for exploratory laparotomy. Ultimately, this circumvented several hours of time which is conventionally required to obtain computed tomography at this institution. As demonstrated in this case, point-of-care ultrasound can be life-saving in resource-limited settings where acquisition time for definitive imaging is often prohibitive.

Gastrointestinal symptoms before and after total pancreatectomy with islet autotransplantation: the role of pancreatic enzyme dosing and adherence.

OBJECTIVES: In a large cohort of subjects undergoing total pancreatectomy with islet autotransplantation (TPIAT), we assessed the prevalence and duration of gastrointestinal (GI) symptoms before and after the procedure to determine the impact of enzyme adherence on GI symptoms. METHODS: Three hundred fifty-six preoperative and postoperative questionnaires were collected from 184 subjects between ages of 5 and 66 years who underwent TPIAT between 2008 and 2011 at the University of Minnesota. Questionnaires were analyzed for self-reported frequency and severity of GI symptoms, pancreatic enzyme usage, and glycemic variability index (GVI). RESULTS: After surgery, patient-reported steatorrhea increased whereas constipation decreased. Gastrointestinal symptoms interfered with daily activity in 44% to 69% of subjects, before and after surgery, despite high reported enzyme adherence. Postoperatively, more than 79% of subjects reported consistent use of enzymes at all meals. Presence of GI symptoms did not vary with adherence. The GVI of 2 had a 2.8-fold increased odds of steatorrhea (95% confidence interval, 1.1-7.0) compared with GVI of 0. CONCLUSIONS: Gastrointestinal symptoms were common after TPIAT; ongoing management is needed. Enzyme nonadherence was not a major contributor to diarrhea/steatorrhea in this cohort. Glycemic variability was closely associated with steatorrhea; poor response to enzyme replacement may complicate diabetes management.

Enterocutaneous fistula as early presentation of Crohn's disease in an adult woman.

Crohn's disease is a chronic transmural inflammatory process that primarily affects the gastrointestinal tract, with several extra-intestinal manifestations. Though patients usually present with vague abdominal pain, initial presentation can be at an advanced stage or with extra-intestinal pathology. The authors report the case of a 59-year-old woman, who presented with a tubo-ovarian abscess that resulted in a protracted non-healing enterocutaneous fistula, which was eventually diagnosed as Crohn's disease approximately 2 years after initial presentation. Relevant literature is reviewed, as well as time-points where an earlier diagnosis could have been made thereby underscoring the importance of considering Crohn's Disease in a non-healing enterocutaneous fistula in an otherwise asymptomatic patient.