Bezoars: a special cause of ileal obstruction in mentally retarded patients.

Abdominal symptoms in mentally retarded patients may pose difficult diagnostic problems due to an unreliable history of disease and incooperation of the patients. The case histories are presented of three patients with bezoars in the ileum. Delayed diagnosis and signs of peritonitis necessitated emergency surgery. All patients could successfully be treated by small bowel resection and primary anastomosis. In mentally retarded patients with abdominal pain a bezoar must be considered.

Mesenteric vein thrombosis as presenting manifestation of hereditary protein S deficiency.

Protein S deficiency is inherited as an autosomal dominant trait. Heterozygotes with a reduction of 50% in the plasma protein S concentration are at risk for the development of venous thromboembolism, often occurring at an early age without an apparent cause. In the majority of the patients thrombosis is restricted to the superficial or deep venous system of the legs. In this case report we describe the presence of mesenteric vein thrombosis in a 30-yr-old man with hereditary protein S deficiency. In his family protein S deficiency was also recognized in his mother, brother, and niece. Both his mother and brother had a history of thrombotic disease.

A nonelemental versus an elemental diet for early postoperative enteral feeding by needle catheter jejunostomy.

In a prospective randomised study the use of an elemental versus a nonelemental diet for early postoperative enteral feeding by needle catheter jejunostomy was investigated. After extensive gastrointestinal surgery, 25 patients received an elemental and 24 patients a nonelemental diet. The incidence of diarrhoea, the effects of the feeding and the costs were evaluated. The occurrence of diarrhoea was observed more frequently in the elemental diet group (14 25 ) compared to the nonelemental diet group (7 24 ), although this difference was statistically not significant (p > 0.05). No difference was found between the two groups in postoperative restoration of total protein and serum albumin levels and the extent of the postoperative weight loss. The costs showed a clear difference: the nonelemental diet was three times cheaper than the elemental diet. For early postoperative enteral feeding by needle catheter jejunostomy we therefore recommend the use of a nonelemental diet.

Haemorrhage from the pancreatic duct: a rare form of upper gastrointestinal bleeding.

Recurrent upper gastrointestinal haemorrhage arising from the pancreatic duct presents diagnostic difficulties. Bleeding can be secondary to pancreatic disease (pancreatitis, pseudocysts) or vascular disorders (aneurysms of the splanchic arteries). Of the 5 cases reported here, 3 involved a ruptured aneurysm of the splenic artery and 2 chronic pancreatitis. Attacks of colicky pain in the left epigastric region associated with haematemesis and/or melaena were characteristic symptoms. Pancreatectomy controlled the bleeding in 4 and ligation of the splenic artery and the pancreatic duct in one. Fifty-five patients with similar pathology have been previously reported, suggesting that this syndrome should be borne in mind when gastrointestinal haemorrhage of obscure origin is encountered. If routine endoscopy does not reveal the site of the haemorrhage and there are no signs of cholestasis, endoscopic retrograde pancreatography (ERP) and selective coeliac arteriography should be performed to evaluate the possibility of haemorrhage from the pancreatic duct. Surgical management depends on the site of the causative lesion.

Needle catheter jejunostomy (NCJ) for early postoperative feeding: experience in 210 patients.

Enteral feeding has many advantages over total parenteral nutrition (TPN) in the early postoperative period. The risk of sepsis is small, the nutrients are cheap and metabolic problems are rare. In the period April 1980 to January 1983, needle catheter jejunostomy (NCJ) was applied in 210 patients after surgery of the oesophagus, stomach, duodenum, liver or pancreas. All but 14 of these patients were fed by NCJ for a certain period postoperatively, NCJ feeding being initiated within 48 hours after the operation in 63% of the cases. In 14 patients, it was decided not to use NCJ feeding because of counter-indications observed postoperatively. The mean duration of the feeding by NCJ was 17 days (range two to 84 days). The complications observed were intraperitoneal leakage in four patients (1.9%), ileus in seven patients (3.3%) and diarrhoea in 54 patients (25.7%). The total number of feeding days was 2,906. This form of feeding resulted in savings of Dfl. 115,00 per patient per day compared with TPN, for a 12,600 Joule intake. NCJ feeding is a relatively safe, economical procedure that can be applied as a matter of routine after abdominal surgery.

Respiratory distress syndrome and its treatment with high positive end-expiratory pressure ventilation.

In a 25-month period, nine patients developed a severe, rapidly progressive respiratory distress syndrome (RDS) and did not respond adequately to conventional respiratory therapy despite the application of positive end-expiratory pressure ventilation (PEEP) up to an upper limit of 15 cm H2O. Treatment with high PEEP was instituted up to 35 cm H2O, in order to achieve a PaO2 higher than 70 mmHg. Massive infusion of electrolyte solutions, colloids and red blood cells were necessary to maintain an adequate circulation that could be monitored by simple parameters such as arterial blood pressure, peripheral skin temperature and urine production. Seven patients (78%) survived. Sepsis was the cause of death in two patients. There were no pulmonary functional or radiological abnormalities, one to 14 months after discharge from the hospital. The upper limit for PEEP should be abandoned and PEEP should be administered according to the needs of each individual patient. As an adequate oxygenation can always be achieved with high-PEEP ventilation, in surgical patients there is hardly, if ever, an indication for ECMO.

Thermodilution technique for measurement of cardiac output during artificial ventilation.

The feasibility of using the thermodilution method to monitor cardiac output during artificial ventilation was studied in anesthetized pigs. Normal saline (0.5 ml) at room temperature was injected into the left ventricle or the right atrium. The dilution curves were detected in the aortic arch and the pulmonary artery, respectively. The ventilation rate was 10 cycles/min at end-expiratory pressures of 0, 5, 10, and 15 cmH2O. For each level, 50 measurements of cardiac output were performed at regular intervals over the ventilatory cycle. The order of measurements were randomly selected. The average of each series of 50 measurements showed excellent correlation with the estimates of cardiac output based on the direct Fick method for oxygen. The maximum difference between the values of cardiac output randomly measured by the thermodilution method was 40% for the left side of the heart and 70% for the right side. However, when the values of cardiac output were sorted according to the specific phases of the respiratory cycle, there was a systematic variation with a small random error. For the left side of the heart, a satisfactory moment of injection for estimation of mean cardiac output appeared to be at the end of the spontaneous expiration. On the other hand, the analysis of cardiac output values at the right side did not reveal any satisfactory moment for injectate administration under changing circumstances, e.g., positive end-expiratory pressure.