The Healthy, Aging, and Diseased Kidney: Relationship with Cardiovascular Disease.

The cardiovascular and renal systems share an intimate physiological relationship, wherein a perturbance in one system may have an adverse effect on the other. Since the burden of renal disease increases with age, there is a considerable interest in the pathophysiology of kidney disease in the geriatric patient population. This review will explore the physiological dynamics behind the increased susceptibility to kidney disease in this population. A better understanding of these pathophysiological changes may lead to improved prevention and management strategies.

Incarcerated Spigelian Hernias: A Rare Cause of a High-grade Small Bowel Obstruction.

A Spigelian hernia is a very rare hernia, making up approximately 0.1% of all abdominal wall hernias. This hernia goes through a defect in the Spigelian fascia which is the part of the transversus abdominis aponeurosis lateral to the rectus muscle, often at the level of the arcuate line, where the fascia is widest and weakest. We present the case of a 77-year-old female with no past surgical history who presented to our teaching hospital with high-grade small bowel obstruction secondary to an incarcerated Spigelian hernia. She was taken to the operating room for a laparotomy and a portion of the small bowel mesentery was found to be strangulated. The hernia was reduced, and the defect was repaired primarily. The diagnosis of a Spigelian hernia can often be difficult to diagnose on history and physical examination alone, but computed tomography (CT) imaging can be a valuable adjunct in diagnosis. Prompt surgical treatment should ensue when the diagnosis of high-grade bowel obstruction is made in a patient with imaging findings consistent with a Spigelian hernia.

Upper Gastrointestinal Bleed Secondary to Duodenal Ischemia.

We would like to present a rare case of postoperative duodenal ischemia managed conservatively. This is an 83-year-old female who underwent an elective costotransversectomy and discectomy. The surgery was complicated by hypotension. Postoperative recovery was complicated by episodes of diarrhea and melena with a hemoglobin drop. Esophagogastroduodenoscopy (EGD) performed revealed diffusely ischemic duodenal mucosa affecting both the first and second parts. Computed tomography angiography failed to find occlusion of blood supply. The patient was managed conservatively with fluids and hemodynamic support. The blood supply to the duodenum is highly collateral making ischemia here rare. In similar case reports of successfully conservatively managed duodenal ischemia, EGD was also performed due to similar rare presentations and diagnostic challenges/uncertainties, despite EGD currently not being considered a useful adjunct in the diagnosis of acute mesenteric ischemia. They were also managed conservatively with fluid replacement, bowel reset, and proper selection of current medications.

Pericecal Hernia Presenting as Acute Appendicitis.

We would like to report an unusual case of a pericecal hernia in a 93-year-old female. The patient did not report a history of previous abdominal surgery and presented with acute abdominal pain, constipation, nausea, and vomiting. Diagnosis was made with computerized tomography and laparoscopy was performed, which was significant for loops of small bowel in the pericecal region in a defect of peritoneum. The small bowel loops were mobilized back in the intraperitoneal location and the defect was closed to prevent further herniation. Our case is an extremely rare presentation of a rare condition, as there have only been five reported cases of pericecal hernias that required immediate surgical intervention and outlined explicit details of the surgical procedure. Pericecal hernias are unusual occurrences and occur more frequently in older women. Since the clinical signs and symptoms mimic acute appendicitis, delays in diagnosis are common. Thus, this case highlights the importance of suspecting strangulated internal hernias in patients with signs and symptoms of acute appendicitis to prevent significant morbidity and mortality.