Intraoperative enteroscopy was performed in 12 patients (median age 68 years) with obscure gastrointestinal bleeding probably of small bowel origin, six of whom were men. All the patients were evaluated by routine haematological, coagulation and biochemical profiles, upper and lower gastrointestinal endoscopies, visceral angiography and/or isotope scanning. All the patients were anaemic. Visceral angiography was useful on three of the 12 occasions on which it was used and isotope scanning was valuable on eight of the 11 occasions it was used. Nine patients had undergone previous laparotomy. Enteroscopy was performed successfully in all cases, with fresh blood and discrete vascular lesions being the chief findings (10 of 12 cases). Segmental resections (n = 8) and local resections (n = 2) were performed in ten patients, with two patients having more than one laparotomy for rebleeding. Five patients developed postoperative complications and there was an operative death and one late death. Three of the ten surviving patients experienced further rebleeding. Intraoperative enteroscopy is now an essential adjunct to laparotomy for gastrointestinal bleeding which has been localized to the small bowel before operation.
ABSTRACT. Left ventricular aneurysms are uncommon complications of myocardial infarction. However, it is important to identify them because they are associated with increased morbidity and mortality. True aneurysms tend to be managed conservatively whereas false aneurysms, because of the risk of rupture, are usually treated with urgent surgery. Distinguishing these two subtypes is therefore critical and cardiovascular magnetic resonance (MR) is being used more frequently to characterise the type of aneurysm as well as to provide clear three-dimensional images of aneurysm morphology. We present a very rare case of a true and a false aneurysm of the left ventricle in the same patient. MR enabled accurate delineation of both aneurysms and the late gadolinium-enhancement images provided evidence confirming both true and false aneurysms to be present. Case reportA 63-year-old female presented with a 2 day history of chest pain. She had experienced brief self-limiting episodes of palpitations associated with dizziness over the preceding month but had otherwise been fit and well. An electrocardiogram showed a regular broad complex tachycardia, consistent with ventricular tachycardia (VT). An attempt at chemical cardioversion with iv amiodarone was unsuccessful, but direct-current (DC) cardioversion reverted the patient to sinus rhythm. A portable chest radiograph showed no obvious abnormality. Transthoracic echocardiography showed an inferior wall left ventricular aneurysm with moderate mitral regurgitation.An adenosine stress cardiovascular magnetic resonance (MR) study was performed (Siemens Avanto 1.5 T, Erlangen, Germany) to look for an ischaemic substrate for VT and to better characterise the inferior wall aneurysm. This revealed no inducible perfusion defect but did demonstrate a large 6 cm wide-necked aneurysm arising from the base of the inferior and inferolateral wall of the left ventricle (LV) close to the mitral valve annulus (Figure 1a). The wall of this aneurysm demonstrated full-thickness late gadolinium enhancement (LGE) with associated mural thrombus (Figure 1b), while the adjacent myocardium in the rest of the inferior and inferolateral wall returned a normal nulled signal. The aneurysm was almost completely surrounded by pericardial fluid (Figure 1a). A further 3.5 cm narrow-necked aneurysm arose from the apex of this larger aneurysm (Figure 1c,d). This smaller aneurysm was adherent to pericardium. Full-thickness LGE was also seen throughout its wall. Further LGE was seen over the pericardial surface close to the smaller aneurysm (Figure 1e). The appearances were therefore those of a large true aneurysm of the inferior wall with an additional false aneurysm arising from its apex.The patient proceeded to surgery urgently given the presence of a false aneurysm. The MR findings were confirmed at surgery, with a large true aneurysm of the basal inferior wall and a small false aneurysm arising from its apex (Figure 2). There was pericardial adhesion to the false aneurysm but not the true aneurysm. The fal...
In a study to assess the potential effect of nonpulsatile hypothermic cardiopulmonary bypass (CPB), intramucosal pH (pHi) of the gastric and colonic mucosae was determined by tonometry (n = 8). During the hypothermic phase of CPB, gastric and colonic pHi did not change significantly. Forty minutes after the start of rewarming, despite increases in the cardiac index and mean arterial blood pressure, gastric pHi fell from 7.53 +/- 0.02 to 7.31 +/- 0.03 (p = 0.017) and colonic pHi fell from 7.50 +/- 0.02 to 7.32 +/- 0.03 (p = 0.028). Forty minutes after the end of CPB both the colonic (p = 0.017) and gastric (p = 0.046) pHi remained depressed below pre-CPB values. The difference in the arterial (pHa) and the gastric mucosal pH changed from -0.097 before CPB to 0.016, 40 minutes after the end of CPB (p = 0.027). This alteration in the pHa-pHi underlines the importance of measuring intramucosal pH by tonometry, since the pHa and pHi may move in opposite directions during episodes of haemodynamic stress. Both the gastric and colonic pHi were found to have a linear correlation with the pHa, although changes in the gastric pHi (r = 0.41, p = 0.018) were more strongly correlated with the pHa than the colonic pHi (r = 0.23, p = 0.19) in the rewarming phase of CPB and the immediate post-CPB period when there was a tendency towards intramucosal acidosis. The development of intramucosal acidosis in the rewarming and immediate post-CPB phases following hypothermic nonpulsatile CPB may impair the gut barrier and predispose patients to the absorption of luminal toxins.
Eliminating the source of bleeding as an emergency, resecting the oesophagus urgently to prevent sepsis and reconstructing the gastrointestinal continuity as an elective case after having the inflammatory processes settled seems to justify the endovascular aortic repair and subtotal oesophageal resection, followed by a gastro-oesophageal reconstruction, as an effective surgical approach.
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