Spontaneous rupture of the oesophagus (Boerhaave's syndrome) is a rare life-threatening disease requiring urgent surgical management. Symptoms can masquerade many other clinical disorders like acute myocardial infarction, dissecting aneurysm or upper gastro-intestinal tract diseases. Without prompt diagnosis and treatment, Boerhaave's syndrome has a very high mortality rate. We report a case of perforation of the distal oesophagus. A 40-year-old male patient presented at the emergency department with a classic history of acute epigastric pain and dyspnoea after an episode of vomiting. On clinical examination we found a firm, tender abdomen and cervical subcutaneous emphysema. Boerhaave's syndrome was suspected on a clinical basis and was confirmed by thoraco-abdominal CT scan, showing an apparent pneumomediastinum and fluid at both lung bases. The patient underwent surgical repair of the distal oesophageal tear by laparoscopy. A mediastinal drain was left behind and a feeding gastrostomy was established. After initial improvement, the patient developed fever and dyspnoea. A thoracic CT scan revealed left-sided empyema. A thoracoscopic drainage of pus was performed and antibacterial and antifungal treatment was adapted. The patient recovered well and was discharged from the hospital 34 days after admission.
Gallstone ileus is a rare complication of cholelithiasis. Only 0,3-0,5% of all patients with gallstones will eventually suffer from this condition. It is well known that there is an increased prevalence of gallstones among patients with Crohn's disease, but gallstone ileus remains even in these patients an unfrequent condition. Because of the rarity of this disease and its presentation as an intestinal (sub)obstruction, mostly without biliary symptoms, diagnosis and surgical treatment are often delayed. We report the case of a 75-year-old woman with a long history of Crohn's disease presenting with intermittent symptoms of intestinal obstruction since several weeks. Symptoms were thought to be due to recurrence of Crohn's disease, but the patient did not respond to steroid therapy. Resection of the diseased ileocolic segment was performed and a large impacted stone was detected proximal of the stenotic segment. With this case report we want to emphasize how easily diagnosis of gallstone ileus can be missed, especially in Crohn's patients and we would like to discuss the different treatment options.
Carotid artery dissection is an important cause of stroke in patients under forty years of age. A dissection of the common carotid artery is relatively rare. This condition can easily be overlooked because symptoms may be lacking or may seem trivial. Carotid artery dissection occurs mostly in previously healthy patients. Urgent treatment however, by means of coumarines or antiplatelet agents, is of life-saving importance, because this disease can lead to permanent neurological deficits or even death. We report a case of a 36-year-old patient who was admitted to the intensive care unit with hemi-paralysis and acute abdomen after a period of severe vomiting. A perforated bulbar ulcer was visible on abdominal CT scan. The patient underwent laparoscopic repair of the perforation. CT scan of the brain showed an extensive area of infarction at the region of the left medial cerebral artery. The cause of the infarction was revealed by angio CT of the supra-aortic arteries, showing a floating thrombus and a possible dissection of the left common carotid artery. Under Clopidogrel therapy, the right-sided paralysis partially recovered. Ten days post-admission, an endarterectomy of the left carotid artery was successfully performed. The patient recovered well and was discharged from the ICU 28 days after admission.
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