Afferent loop syndrome 7-years post Roux-en-Y gastrojejunostomy: An often-forgotten pancreatitis cause. A case report.

Afferent loop syndrome is a rare post-operative complication following upper gastrointestinal bypass surgeries, usually occurring within the first two weeks post-operation. This case report, however, outlines afferent loop syndrome almost a decade post-surgery, which was managed conservatively. A 54-year-old woman presented with a few days' history of epigastric pain, vomiting, and constipation. She had undergone a sleeve gastrectomy and was converted to a Roux-en-Y gastrojejunostomy for weight loss 9 and 7 years ago, respectively. Serum lipase was elevated at 1410 IU/L. Computed tomography showed high-grade proximal small bowel obstruction, involving the efferent and afferent loops of the Roux-en-Y gastric bypass. The patient was given intravenous rehydration, electrolyte replacement and had a nasogastric tube inserted. She was discharged on day 5 of admission without significant sequelae. Afferent limb syndrome should be considered in patients with altered upper gastrointestinal anatomy who present with pancreatitis, regardless of the time period post-operatively. Future guidelines should further more outline the factors indicated for surgical versus conservative management.

Massive gastrointestinal bleed due to a primary aortoenteric fistula.

A man in his 60s attended emergency for acute-onset abdominal pain and haematemesis. Requiring resuscitation, a CT abdomen/pelvis revealed a primary aortoenteric fistula actively bleeding into the duodenum. His background included a previous severe Q-fever infection and a heavy smoking history. Despite attempts at resuscitation and an emergent surgical attempt at haemostasis, the patient did not survive the massive gastrointestinal haemorrhage.Even in less severe cases, management of aortoenteric fistulas is tricky. Blood cultures and angiographic imaging are important investigations in guiding surgical approach. The pathology tends to have a significant rate of mortality even at tertiary-level vascular surgical centres.

A curious adult case of small bowel volvulus with congenital malrotation.

Intestinal volvulus is defined as a twisting of the bowel on its mesentery. It itself is a rare occurrence, with documented incidence of 1% as the cause of all small bowel obstruction, with further 0.82% of them being associated with intestinal malrotation. The classical radiographic feature described in literatures is the whirlpool sign. We herein report a rare presentation of congenital malrotation causing a small bowel obstruction in a 43-year-old man. The patient presented with acute abdominal pain and underwent an emergency laparotomy and resection of small and large bowel (total of 3 m with primary anastomosis), with an estimated 2.6 m of viable small bowel left. The patient had a prolonged recovery complicated by another relook operation, superior mesenteric vein thrombus and a high-output stoma with subsequent electrolyte derangements and acute kidney injury. He was discharged on Day 26 and had been seen in the outpatient department with good functionality.

Laparoscopic Management of Hepatic Abscess From Ingested Chicken Bone.

A 68-year-old man presented to the hospital with severe right upper abdominal pain, fevers, nausea and lethargy. He deteriorated into septic shock and was found to have a hepatic abscess on computer tomography imaging. After multiple investigations and continual deterioration, he underwent an exploratory laparoscopy which revealed a chicken bone within the liver parenchyma resulting in a large hepatic abscess. The patient required a second laparoscopic washout and prolonged antibiotics, subsequently recovering well. This rare case highlights the difficulty in diagnosing hepatic abscesses caused by gastrointestinal foreign bodies, and successful management with laparoscopic surgery.

Epidemiology of biopsy-proven glomerulonephritis in Queensland adults.

AIM: There is a paucity of data pertaining to the incidence of biopsy-proven glomerulonephritis (GN) in Australia. This retrospective study aims to review the data from all adult native renal biopsies performed in the state of Queensland from 2002 to 2011--comparing results with centres from across the world. METHODS: Pathology reports of 3697 adult native kidney biopsies were reviewed, of which 2048 had GN diagnoses. Age, gender, clinical indication and histopathology findings were compared. RESULTS: The average age at biopsy was 48 ± 17 years. Male preponderance was noted overall (∼60%), with lupus nephritis being the only individual GN with female predilection. The average rate of biopsy was 12.04 per hundred thousand people per year (php/yr). Nephrotic and nephritic syndromes comprised approximately 75% of all clinical indications that lead to GN diagnoses. IgA nephropathy (1.41 php/yr) was the most common primary GN followed by focal segmental glomerulosclerosis (1.02 php/yr) and crescentic GN (0.73 php/yr). Diabetic nephropathy (0.84 php/yr), lupus nephritis (0.69 php/yr) and amyloidosis (0.19 php/yr) were the most commonly identified secondary GN. CONCLUSION: IgA nephropathy is the predominant primary GN in Queensland, and nephrotic syndrome the most common indication for a renal biopsy. While crescentic GN incidence has significantly increased with time, focal segmental glomerulosclerosis incidence has not shown any trend. Incidence of GN overall appears to increase with age. The annual rate of biopsy in this study appears lower than previously published in an Australian population.

Dialysis and pregnancy in end stage kidney disease associated with lupus nephritis.

Female patients with systemic lupus erythematosus are often of childbearing age at diagnosis, and though fertility in these patients is similar to the general population, successful pregnancy remains a rare occurrence. This incidence is, however, increasing and the management of these high risk pregnancies is often further complicated by the patient's need for dialysis as a result of lupus nephritis (LN). We share our experience in managing two LN patients with successful pregnancies, one on automated peritoneal dialysis and the other on haemodialysis, as well as a review of cases in the literature.