1. ER/SER combine conference
Present 施宏謀
Supervisor 李強忠醫師
Moderator 邱德發主任

2. Case present Name 張先生 Age: 78-year-old Gender : male 到院時間:
2009/12/03 22:51
檢傷主訴: 腹痛嘔吐
檢傷分類: 三級
Vital sign:
BT: 36.8’C
PR: 106 / min
RR: 20 / min
BP: 171/115 mmHg
SaO2: 95%
GCS: E4V5M6

3. Chief complaint
Abdominal fullness for 1 day

4. Brief history
Abdominal distension after dinner since last night (more than 1 day)
Nausea
vomiting once this morning
No abdominal pain

5. Brief history No fever No flank pain No diarrhea No jaundice PH:
1. Duodenal ulcer s/p operation > 30 years ago
2. Old TB s/p treatment

6. Physical examination Conscious clear ; E4V5M6
HEENT: not anemic, no icteric sclera
Chest : clear breathing sound
Heart : RHB, no murmur
Abdomen: soft, normoactive bowel sound
mild tenderness over epigastric area,
no rebounding pain, no Murphy’s sign,
no Mcburney point tenderness

7. Additional Hx and PE More information for suspected GI tract disease：
Intake / Appetite ?
Bowel habit / stool or flatus passage?
Complete surgical history
Pattern and content of emesis

8. Initial impression ? (ER 0:13)
Acute gastroenteritis?
Intestinal adhesion
Initial order :
Metoclopramide 1 amp. Im. stat
KUB
Do you agree?

9. Differential diagnosis
Progressive and painless abdominal distention with non-bilious emesis
Symptoms favor UGI disease
Acute gastritis
Gastric outlet obstruction (tumor)
Proximal Intestinal adhesive ileus
Focal inflammation or mass effect : Pancreatitis, external tumor compression

10. KUB

11. 40 minutes later (ER 0:43) Still nausea, epigastragia 
Suspected free from KUB
CBC/DC
Cr, AST, Amylase, lipase, sugar, Bilirubin, CRP, Na, K,
NPO
EKG
CXR (standing)
L’T abdomen decubitus
IVF: N/S run 80ml/hr

12. CXR

13. L’t decubitus

14. Lab data Sugar 161 mg/dL Creatinine(B) 1.02 mg/dL Amylase (B) 155 U/L
WBC /uL
RBC million/uL
Hemoglobin g/dL
Hematocrit %
MCV fL
MCH pg/Cell
MCHC g/dL
RDW %
Platelets /uL
Segment %
Lymphocyte %
Monocyte %
Eosinophil %
Basophil %
Sugar mg/dL
Creatinine(B) mg/dL
Amylase (B) U/L
Lipase U/L
Total Bilirubin mg/dL
AST (GOT) U/L
Na mEq/L
K mEq/L
CRP mg/L

15. ER (1:47) Persisted mild epigastric pain ill looking
Tenderness over epigastric area, diffuse, no muscle guarding or rebounding pain
Suspected free air from KUB
 Arrange abdominal CT (C+/-)

16. Abdominal CT (ER 2:39)

17. Observation Diagnosis : favor adhesion ileus hx of DU s/p op; old TB
On NG with decompression (non-bilious)
IVF : D5S 1000ml + primperan 1amp run 125ml/hr

18. CT report (ER 11:10)
S/P subtotal gastrectomy and antecolic B-II anastomosis
Dilatation of the fluid-filled afferent loop
Twisting of mesentery at LUQ, suggestive of volvulus
Mild dilatation of the P-duct and extrahepatic bile duct
Minimal ascites, no free air
IMPRESSION:
Afferent loop obstruction probably caused by volvulus

19. ER course 12:40 Consult T-GS abdomen : Distended, guarding
Tenderness : diffuse over upper abdomen
more over RUQ and epgiastrium
bowel sounds : silent
no flatus passage
NG : nearly no bilious content

20. GS consultation image : A-loop dilatation,
Whirl sign over LUQ, suspect volvulus
<< impression >>
favor A-loop syndrome
<< plan >>
arrange emergent laparotomy
antibiotic
IVF hydration
ADMISSION

21. OP finding
1. A segment of E-loop, length 40 cm, herniated through meseteric defect with incarceration, which resulted in distension of duodenum
2. The herniated bowel was reduced through the defect, and the color and motility returned as unaffected bowel
3. Several pathcy ecchymosis was noted on the mesentery of the herniated bowel. Some pachy lesion was also noted on duodenum
4. Fluid accumulation at retroperitoneal cavity
5. No bowel perforation was noted
6. The mesenteric defect was repaired with approximation with adjacent bowel

22. Final diagnosis Patient discharge home 7 days later
s/p subtotal gastrectomy with B-II reconstruction with E-loop internal hernia
Secondary afferent loop syndrome

23. Discussion Billroth’s II reconstruction complication
E-loop obstruction
CT signs of internal hernia
Causes of acute afferent loop obstruction

24. Billroth’s II reconstruction

25. Billroth’s II complication
77 in 310 (24.8%) developed postoperative general and surgical complications
Abdominal collection 12 (3.9%),
Pancreatitis/ pancreatic fistula 10 (3.2%)
Intestinal occlusion/prolonged ileus 8 (2.6%)
Bleeding 7 (2.3%)
Wound infection 7 (2.3%)
Anastomotic leakage 6 (1.9%)
Treatable gastric cancer s/p subtotal gastrectomy and BII reconstruction
77/310
Ref. Postoperative complications and functional results after subtotal gastrectomy with Billroth II reconstruction for primary gastric cancer. Dig Dis Sci Aug;52(8): Epub 2007 Apr 3.

26. Postgastrectomy syndrome
Early and late Dumpling syndrome
Metabolic disturbance (IDA, vitamin B12, Fat)
Afferent loop syndrome
Efferent Loop Obstruction
Alkaline reflux gastritis
Retained antrum syndrome
Early = rapid passage -> diarrhea, abdominal pain, chest pain …
Late = hyper G  hyperinsulin  hypoglycemia
retained antrum syndrome = antrum in Duodenum and 大量gastrin  PUD
Ref. Sabiston Textbook of Surgery, 18th Edition

27. E-loop obstruction
Most common: Herniation of the limb behind the anastomosis
Right-to-left direction
Compression afferent loop or compromise blood supply
Occur any time but 50% within 1st month
Ref. Sabiston Textbook of Surgery, 18th Edition

28. E-loop obstruction Initial complaints： LUQ colicky pain
Bilious vomiting
Abdominal distention
Diagnosis base on UGI series with barium contrast
Treat with operative intervention
Ref. Sabiston Textbook of Surgery, 18th Edition

29. CT signs of internal hernia

30. Mesenteric swirl sign
shows twisting of mesenteric vessels and fat around the central superior mesenteric artery axis
Ref. Sensitivity and specificity of eight CT signs in the preoperative diagnosis of internal mesenteric hernia following Roux-en-Y gastric bypass surgery Clin Radiol Apr;64(4): Epub 2008 Dec 16.

31. Hurricane eye sign
Tubular shape or column of mesenteric fat in corkscrew configuration
Ref. Sensitivity and specificity of eight CT signs in the preoperative diagnosis of internal mesenteric hernia following Roux-en-Y gastric bypass surgery Clin Radiol Apr;64(4): Epub 2008 Dec 16.

32. Mushroom sign shows a mushroom
shape to the mesenteric root as it herniates through
the jejuno-jejunostomy defect, bordered by the superior
mesenteric artery (thin arrow) and a more distal
mesenteric arterial branch (thick arrow).
Ref. Sensitivity and specificity of eight CT signs in the preoperative diagnosis of internal mesenteric hernia following Roux-en-Y gastric bypass surgery Clin Radiol Apr;64(4): Epub 2008 Dec 16.

33. Engorged mesenteric nodes
Multiple enlarged lymph nodes (arrows) clustered together within
the mesentery around a central vascular axis
Ref . Sensitivity and specificity of eight CT signs in the preoperative diagnosis of internal mesenteric hernia following Roux-en-Y gastric bypass surgery Clin Radiol Apr;64(4): Epub 2008 Dec 16.

34. CT signs of internal herniation
Ref. Sensitivity and specificity of eight CT signs in the preoperative diagnosis of internal mesenteric hernia following Roux-en-Y gastric bypass surgery Clin Radiol Apr;64(4): Epub 2008 Dec 16.

35. Acute afferent loop obstruction
Angulations of the afferent limb
Internal herniation behind the efferent limb
Stenosis of the gastrojejunal anastomosis
Redundant twisting of the afferent limb with a resultant volvulus
Adhesions involving the afferent limb
Ref. Sabiston Textbook of Surgery, 18th Edition

36. Reference Sabiston Textbook of Surgery, 18th Edition
Postoperative complications and functional results after subtotal gastrectomy with Billroth II reconstruction for primary gastric cancer. Dig Dis Sci Aug;52(8): Epub 2007 Apr 3.
Sensitivity and specificity of eight CT signs in the preoperative diagnosis of internal mesenteric hernia following Roux-en-Y gastric bypass surgery Clin Radiol Apr;64(4): Epub 2008 Dec 16.

37. Take home message Difficulty in diagnosing internal hernia
CT signs of internal hernia
Early intervention if hernia presented

38. Thanks for your attention