Bezoars are aggregates of undigested materials that accumulate in the gastrointestinal lumen. They are a rare cause of small bowel obstruction and are mostly diagnosed in patients with small bowel disease. Patients with panhypopituitarism are more susceptible to developing metabolic and haemodynamic instability, particularly during perioperative period.We present the case of a male patient with small bowel obstruction secondary to a bezoar. The patient was admitted to the hospital due to upper abdominal pain and emesis, presenting with clinical signs of shock. He had a history of iatrogenic panhypopituitarism and had been submitted to a bilateral inguinal hernioplasty 15 days before. Abdominopelvic computed tomography with angiography revealed small bowel obstruction secondary to a bezoar. Stress-dose hydrocortisone was administered to treat the underlying haemodynamic instability, followed by exploratory laparotomy. The bezoar was removed and eventually the patient recovered with a tapering regimen of hydrocortisone.The diagnosis of small bowel obstruction secondary to bezoar can be challenging. The shock could be related to an adrenal crisis precipitated by the bezoar in the setting of increased susceptibility due to the recent surgery.
Objective
To analyze and compare COVID-19 patient characteristics, clinical management
and outcomes between the peak and plateau periods of the first pandemic wave
in Portugal.
Methods
This was a multicentric ambispective cohort study including consecutive
severe COVID-19 patients between March and August 2020 from 16 Portuguese
intensive care units. The peak and plateau periods, respectively, weeks 10 -
16 and 17 - 34, were defined.
Results
Five hundred forty-one adult patients with a median age of 65 [57 - 74]
years, mostly male (71.2%), were included. There were no significant
differences in median age (p = 0.3), Simplified Acute Physiology Score II
(40
versus
39; p = 0.8), partial arterial oxygen
pressure/fraction of inspired oxygen ratio (139
versus
136;
p = 0.6), antibiotic therapy (57%
versus
64%; p = 0.2) at
admission, or 28-day mortality (24.4%
versus
22.8%; p =
0.7) between the peak and plateau periods. During the peak period, patients
had fewer comorbidities (1 [0 - 3]
versus
2 [0 - 5]; p =
0.002) and presented a higher use of vasopressors (47%
versus
36%; p < 0.001) and invasive mechanical
ventilation (58.1
versus
49.2%; p < 0.001) at admission,
prone positioning (45%
versus
36%; p = 0.04), and
hydroxychloroquine (59%
versus
10%; p < 0.001) and
lopinavir/ritonavir (41%
versus
10%; p < 0.001)
prescriptions. However, a greater use of high-flow nasal cannulas (5%
versus
16%, p < 0.001) on admission, remdesivir
(0.3%
versus
15%; p < 0.001) and corticosteroid (29%
versus
52%, p < 0.001) therapy, and a shorter ICU
length of stay (12 days
versus
8, p < 0.001) were
observed during the plateau.
Conclusion
There were significant changes in patient comorbidities, intensive care unit
therapies and length of stay between the peak and plateau periods of the
first COVID-19 wave.
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