This paper represents the first description of the use of oral lumbrokinase in the treatment of chronic coronary artery disease with objective assessment using MPI. Oral lumbrokinase improves regional myocardial perfusion in patients with stable angina.
HighlightsA rare variation of Abernethy malformation with Associated small bowel anomaly.A case of emergency surgery in a patient with these anomalies.Pre-operative imaging and intra-operative findings are presented.The embryology of these anomalies pertaining to the case are discussed.
Hydrocephalus is generally not reversible thus the insertion of ventriculoperitoneal (VP) shunts remains a cornerstone for the longterm management of this condition. 1 A review of practice over 1 year in the United States found that 8300 new VP shunts were inserted and that the median age of patients undergoing shunt insertion and revision procedures was 31 years old. 1 Small bowel obstruction (SBO) is an uncommon complication of VP shunts. We report the case of a young adult female who developed this complication as a consequence of her VP shunt forming a knot around the small bowel and its mesentery. We believe this is the first reported case of a VP shunt inserted in a paediatric patient where knot formation presented in adulthood with SBO.A 32-year-old woman with global developmental disability from a high-level care facility presented to the emergency department with a 2-day history of obstipation and bilious vomiting for 24 h. The patient had a history of recurrent SBO with five admissions for non-operative management in the previous 2 years. The past medical history was significant for hydrocephalus secondary to complications of neonatal bacterial meningitis with the insertion of a VP shunt in infancy. Multiple revisions of the shunt were required in early childhood, but none since the age of 8 years. On examination, the abdomen was soft but distended and mildly tender. Plain abdominal X-ray confirmed SBO and the shunt was coiled in the mid-abdomen, unchanged from previous imaging. She was managed initially with bowel rest and intravenous fluids but resisted attempts to place a nasogastric tube (NGT). Computed tomography of the abdomen was performed and this demonstrated a SBO associated with the VP shunt (Fig. 1). After neurosurgical consultation, it was decided to proceed with operative treatment. At laparotomy, the VP shunt was encased in a dense fibrous tract and tightly knotted around the mesentery of a large portion of the ileum (Fig. 2). The involved loops were thickened and markedly dilated with dense fibrotic adhesions consistent with chronic obstruction. The shunt was dissected out and shortened by 25 cm. Extensive adhesiolysis was performed. The patient was kept intubated post-operatively to facilitate the use of a NGT in the anticipation that an ileus would develop. Her post-operative course was complicated by aspiration pneumonia after extubation and she was discharged from hospital on a normal diet 2 weeks after her surgery.The placement of shunts into the peritoneal cavity is the most common method of shunting cerebrospinal fluid in hydrocephalus. Complication rates are approximately 30% in the first year and continue at a rate of 4-5% per year thereafter. 2 Complications are more common temporally close to the insertion and among children. 3 Intra-abdominal complications of VP shunts are uncommon, with the exception of infection and shunt obstruction, 2 although a large range of complications have been described including bowel obstruction, pseudocyst formation, inguinal hernia and hydroco...
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