Bile Vomiting Research Articles

23. SURGICAL MANAGEMENT OF A HIGHLY COMPLEX CASE OF BILIARY LEAK FOLLOWING HEPATOBILIARY SURGERY

Abstract Introduction Biliary leaks are a frequent complication of hepatobiliary surgery. We present a particularly complex case. Clinical case A 46-year-old man underwent S4-8 hepatic bisegmentectomy for hepatocellular carcinoma. Two months later he underwent percutaneous drainage of a liver collection and later endoscopic placement of plastic biliary stents. Due to the persistence of the leak, it was decided to intervene surgically by suturing the biliary leak, draining the main bile duct using a Kehr drain, and cholecystectomy, with apparent resolution. Two months later, sudden dyspnea with yellow-green emission, persistent cough, and episodes of bile vomiting appeared. CT of the chest and abdomen confirmed the presence of a biliobronchial fistula and a subdiaphragmatic biloma connected to the hemidiaphragm and initial parenchymal irritation. Percutaneous drainage of the biliary collection and thoracotomy surgery (transdiaphragmatic repair of biliary fistula, atypical lung resection of the right lower lobe, pleural cleaning, and diaphragmatic plastic surgery) were performed. One month later, with the subdiaphragmatic collection persisting, a Roux-en-Y biliojejunal anastomosis, transjejunal loop, and liver drainage (U tube) were performed, along with drainage of the interhepatodiaphragmatic collection. Subsequently, one month later, due to the persistence of the bile leak with interhepatodiaphragmatic collection, another Roux-en-Y anastomosis of the parenchymal fistula in the residual cavity was performed. After 14 days, the patient was discharged in good clinical condition, which lasted over time, without collections. Discussion This case illustrates the complexity that can be associated with a common complication of hepatobiliary surgery.

Ladd’s Syndrome in Newborns

Ladd’s syndrome is a violation of intrauterine intestinal rotation. The midgut remains fixed at one point at the origin of the superior mesenteric artery. As a result, conditions are created for the occurrence of a volvulus around the root of the mesentery and acute strangulation intestinal obstruction develops. Ladd’s syndrome includes three features: a high position of the caecum dome, duodenal hyperfixation, and lack of mesenteric fixation. In newborns, this condition is manifested by acute complete high strangulation intestinal obstruction, up to the development of shock. Examination for suspected Ladd’s syndrome should be comprehensive and include a survey abdominal radiography, abdominal ultrasound, gastric and duodenal radiography with oral contrast, irrigography. The article considers clinical cases of Ladd’s syndrome in newborns at the age of 3 and 5 days of life. Echograms made in B-mode using color Doppler sonography are presented. The high informativeness of ultrasound diagnostics for the detection of this syndrome in newborns with a clinic of bile vomiting is shown. In one of the observed cases, a pathognomonic echographic symptom of midgut volvulus was established (a whirlpool sign). In the second observation, a clearly defined vascular ring was not detected due to 180° torsion, which was subsequently confirmed intraoperatively.

Argon plasma coagulation combined with pneumatic dilatation for the treatment of duodenal stenosis: A case report

We present an alternative therapeutic approach for the treatment of secondary duodenal stenosis with pneumatic dilation combined with the use of argon plasma. We present a patient with a history of duodenal atresia corrected with duodenal-duodenal anastomosis, who presented late duodenal stenosis, presenting progressive bile vomiting and intolerance to the oral route. He underwent pneumatic and argon plasma dilatation. Procedure performed under general anesthesia. The dilations were successful, he did not present immediate complications. Presents adequate evolution 2 year after the last dilation event. Pneumatic dilation combined with argon plasma in this patient showed adequate effectiveness in duodenal dilation, without immediate and mediate complications, presenting an adequate evolution. This suggests that this technique could be reproduced by pediatric endoscopist surgeons and avoid the open surgical procedure.

Laparoscopic treatment of duodenal atresia associated with situs inversus abdominis in a newborn

Introduction. A combination of congenital duodenal obstruction (CDO) and situs inversus abdominis (SIA) is an extremely rare case. The present article describes a laparoscopic technique applied for the care in such patient.Case presentation. A newborn girl was admitted to the hospital on the 4th day of her life with regular bile vomiting and weight loss. Examination revealed CDO combined with SIA. After preoperative preparation and condition stabilization, the child was operated on and Kimura duodenoduodenoanastomosis was put. After the performed treatment, duodenal patency was restored. The patient was discharged home in a satisfactory state. She had complete enteral feeding with a good dynamics of weight gain.Conclusion. The described case demonstrates the effectiveness of laparoscopic approach in patients with CDO and SIA hospitalized in a regional children`s hospital.

Do obesity and diabetes increase the frequency and risk of bile reflux gastritis post-cholecystectomy?

<br><b>Introduction:</b> Biliary gastropathy is a disease characterized by upper abdominal pain, frequent heartburn, nausea, and vomiting of bile. It is caused by the backward flow of duodenal fluid into the stomach and esophagus.</br> <br><b>Aim:</b> A retrospective cohort study was performed to estimate the prevalence and risk factors of bile reflux gastritis secondary to cholecystectomy and to evaluate the endoscopic and histopathologic changes in gastric mucosa caused by bile reflux gastritis.</br> <br><b>Materials and methods:</b> The study involved 64 patients with epigastric pain and/or dyspeptic symptoms during the period from January 2018 to December 2020 who presented to Zagazig University Hospitals. The subjects were divided into two groups: the control group (CG), with 30 subjects who had never undergone any biliary interventions, and the post-cholecystectomy group (PCG), consisting of 34 patients who had undergone cholecystectomy.</br> <br><b>Results:</b> The prevalence of bile reflux gastritis was 16.7% in the CG and 61.8% in the PCG. In both groups, diabetes, obesity, increased gastric bilirubin, and increased gastric pH were risk factors for bile reflux gastritis (r = 0.28, 0.48, 0.78, and 0.57, respectively). However, there were no correlations between age, sex, epigastric pain, heartburn, vomiting, and the presence of bile reflux gastritis.</br> <br><b>Discussion:</b> Bile reflux gastritis is a common complication following cholecystectomy and is more common among obese and diabetic patients.</br&gt.

Nonsurgical treatment of intussusception in pediatric patient

Purpose: In this study, to show that the pre-diagnosis of intussusception should be kept in mind if there is a suspicious appearance in the abdominal X-ray in pediatric patients with intermittent abdominal pain or discomfort in the form of colic, even though there is no rectal bleeding and bile vomiting. Material and methods: In this retrospective, single-center, cross-sectional descriptive study, we examined the records of 33 patients who were followed up due to intussusception between the ages of 0-18 at Pamukkale University Faculty of Medicine Pediatric Surgery Clinic between September 2017 and September 2020. Patients were evaluated in terms of demographic data, hospital admission times, data on imaging methods, pneumatic reduction and surgery. Results: The average age was 37.4±18.8 months. The time from the onset of the patients' complaints to admission to the hospital was 57.3±66.1 hours. 10 patients had ileus findings on abdominal radiography. 30 patients had the image of a champagne glass, typical of intussusception. Ultrasonography showed mesentery lymphadenopathy in 20 patients, and leading point in 3 patients. Ultrasonography of 1 patient was normal, but when the abdominal radiography of this patient was evaluated, there was a suspicion for intussusception. When this patient was evaluated under fluoroscopy and pneumotic reduction was performed. 3 patients who had leading point. Meckel's diverticulum was detected in 1 of 3 patients, Burkitt's lymphoma in 1, and neurofibroma in 1. Conclusion: Pneumatic reduction is more preferred as it is a method that the surgeon can do in the operating room, under fluoroscopy and alone. Another advantage of trying pneumatic reduction under fluoroscopy in the operating room is to try the nonoperative technique in a controlled manner in patients with ileus findings and late arrivals.

The risk of development of acute kidney injury in full-term infants with administration of methylxanthines

Exploring new possibilities for the use of methylxanthines to prevent the development of acute kidney injury (AKI) in full-term infants with perinatal asphyxia. Aim: to evaluate the efficacy and safety of methylxanthines in full-term infants for the prevention and conservative treatment of acute kidney injury. Materials and methods. To test the effectiveness of the proposed method of AKI treatment, 38 infants were chosen and divided into 2 groups by random selection. Nursing and intensive care were according to current legislation (Order of the Ministry of Health of Ukraine No. 225 of March 28, 2014). The main group (n = 20) received therapy with caffeine citrate, the comparison group (n = 18) – theophylline. Both of these drugs were used to prevent the development of acute kidney injury – stage II and III according to KDIGO. Results. A significant difference in serum creatinine was found in the main group - the level of serum creatinine was higher than in the comparison group, but did not exceed the physiological norm. GFR on the 3rd day of life was higher with administration of theophylline, but in the group of caffeine did not exceed the reference values of the norm. No differences between urea levels and diuresis rates were found in the groups. The initial results indicate the lack of statistical significance when using various drugs of the methylxanthine group, namely theophylline and caffeine citrate. This is explained by the fact that in the main group 65.00 % (n = 13) of patients had AKI stage 0 according to KDIGO, and 35.00 % (n = 7) had stage I. In the comparison group, 55.56 % (n = 10) and 44.44 % (n = 8), respectively. Stages II and III in both groups of the study did not develop, the obtained data are equivalent – U = 163,00; P = 0,6296. However, the use of caffeine citrate may become a priority due to a better safety profile compared to theophylline. Caffeine is less likely to cause adverse effects in the form of non-pathological bile vomiting and has significantly lower relative risk of non-pathological bile vomiting in infants (RR 0.26 (95 % CI 0.10; 0.66)). Conclusions. Conservative methylxanthine therapy in full-term infants with perinatal asphyxia prevents the development of stages II and III of AKI according to KDIGO. However, it is necessary to continue the collection of material to increase the statistical significance, as well as to study the early and long-term consequences of this therapy.

Congenital short bowel syndrome: a case report and review of the literature

Congenital short bowel syndrome is a rare condition of the newborn, with several reports demonstrating high mortality. For the first time in Russia, we report a case of treatment of a newborn girl with genetically confirmed congenital short bowel syndrome, and also provide a review of the literature on this syndrome. After birth, the child experienced constant vomiting of bile with a progressive decrease in body weight. The laparotomy for congenital adhesions between the loops of the small intestine with severe violations of the evacuation function revealed that the small bowel was 50 cm in length, confirming the diagnosis of congenital short bowel syndrome. The genetic test, using whole exome sequencing, identified a homozygous mutation in the CLMP gene in this patient. A positive result in the postoperative period was achieved using the protocol for the management of patients with short bowel syndrome. Currently, the girl is 11 months old, body weight is 9 kg, development is harmonious. Long-term survival of children with congenital short bowel syndrome is now possible if enteral feeds are introduced early to promote intestinal adaptation, with subsequent weaning off parenteral nutrition.

Femoral Artery Thrombosis in a Very Low Birth Weight Preterm Newborn

Abstract Tromboses are considered to be rare disorders in the pediatric population. However, they occur more frequently during the neonatal period. Potential risk factors for thrombosis onset include frequent use of peripheral, umbilical or central venous / arterial catheters, inflammation, disseminated intravascular coagulation, liver disorders, hypovolemia, asphyxia, congenital heart disease, polycythemia and dehydration. On the seventh day of life in male premature infant born in 29th / 30th gestation week, we noticed an increased level of inflammatory parameters. The patient’s right leg was edematous and cold with immeasurable pulse and pressure over the femoral artery, mottled skin and no spontaneous mobility. In the following days, edema becomes generalized and abdominal meteorism with bile vomiting appeared. Vascular surgeon established a diagnosis of the acute femoral artery stenosis (CW Doppler). We initiated continuous infusion of unfractionated heparin, but due to the development of hemorrhagic syndrome, next day we replaced it with low molecular weight heparin. The hemorrhagic disease was treated with tranexamic acid, fresh frozen plasma and concentrated platelets of the corresponding blood group. Signs of recirculation were registered with a palpable femoral pulse. CW Doppler confirmed complete recovery. In spite of the fact that antithrombotic therapy can cause numerous complications, it should be considered in vital indications.

Bilious Vomiting Syndrome in Dogs: Retrospective Study of 20 Cases (2002-2012).

Bilious vomiting syndrome (BVS) is a condition historically associated with early morning vomiting of bile, but it is otherwise poorly characterized. The vomiting is thought to result from a reflux of duodenal fluid into the gastric lumen causing mucosal irritation. Medical records from Colorado State University Veterinary Teaching Hospital (CSUVTH) were searched for "canine" and "bilious vomiting syndrome" between 2002 and 2012. Visual inspection confirmed a diagnosis of BVS during the case history. The diagnosis remained BVS for the duration of the dog's contact with the hospital in 17 cases. Therapy involved frequent feedings, late evening meals, gastric acid reducers, prokinetics, and gastroprotectants. Twelve dogs improved with therapy. Five dogs did not improve or were lost to follow-up. The diagnosis of BVS was supplanted in three cases with gastric adenocarcinoma, dietary indiscretion, and hepatopathy. The patient most likely given a diagnosis of BVS would be a young, mixed-breed, castrated male dog with a chronic history of vomiting bile. Response to therapy suggests abnormal gastrointestinal motility, local gastritis, gastric pH, or stimulation of the emetic center may be important factors in BVS. Dogs diagnosed with BVS rarely received a diagnostic evaluation sufficient to qualify it as a diagnosis of exclusion.

Contrast-enhanced CT as a preferred diagnostic tool in sigmoid volvulus in a 14-year-old girl

Summary Volvulus of the sigmoid colon is rare in children although it is a common cause of large bowel obstruction in elderly people. We report a case of sigmoid volvulus in a 14-year-old girl with intellectual disability. She had a 1-year history of chronic diarrhea despite supportive treatment. She was brought to the emergency department because of intermittent abdominal pain associated with vomiting of bile and passage of bloody stools. A plain X-ray showed dilated bowel loops. A contrast-enhanced computed tomography (CT) scan showed both limbs of the distended loop tapering in size and forming a round soft-tissue mass with whirled configuration in the left colonic compartment. Preoperatively, volvulus was suspected. Exploratory laparotomy disclosed a markedly distended sigmoid colon packed with fecal material and a counterclockwise rotation of 720 degrees with strangulating gangrene. The volvulus was untwisted, and a 65-cm segmental resection of the colon and primary anastomosis were performed. The patient was discharged on the 19th day following an uneventful postoperative course. We believe that a contrast-enhanced CT scan is a useful tool in the diagnosis of sigmoid volvulus.

Bile vomiting in paediatrics: what do we really know?

Bile vomiting is clinically significant in neonates and children, indicating intestinal obstruction until proven otherwise. The aim of this study was to assess whether nursing staff within a children's hospital were able to accurately identify bilious vomiting and if a deficiency existed, whether educational posters could rectify this problem. A primary audit was conducted in the Royal Aberdeen Children's Hospital evaluating the ability of nursing staff to identify bile vomit and its significance. Educational posters were distributed and a secondary audit was conducted after six months to complete the audit cycle. The second audit also compared the knowledge of different medical professionals. In the primary audit, 41% of nurses selected the colour yellow, compared with 18% of nurses in the second audit with approximately 70% selecting dark-green. Thirty-three percent of nurses in the primary audit confirmed intestinal obstruction as the cause of bile vomiting, compared with 64% of nurses in the secondary audit. In conclusion, this study identified a deficiency in the recognition of bile vomiting among nurses, but demonstrates that the use of educational posters can significantly improve knowledge. This can be beneficial in the early recognition of this potential surgical emergency.

Recurrent small bowel ischemia in a patient with paroxysmal nocturnal hemoglobinuria

A 33-year-old female presented with a history of recurrent epigastric pain and vomiting of bile, accompanied by duodenal wall thickening seen on an abdominal CT scan and a congestive, bluish and ischemic-looking duodenal mucosa as visualized by endoscopy. The patient's medical history was notable for paroxysmal nocturnal hemoglobinuria diagnosed 15 years before. The patient was usually treated with danazol and warfarin and she received regular blood transfusions for hemolytic anemia. Medical history and physical examination. Blood tests, coagulation study, search for thrombophilic disorders and small vessel vasculitis. Stool culture and virology. Test for autoantibodies. Abdominal CT scan. Upper gastrointestinal endoscopy with duodenal biopsies. Small bowel ischemia complicating paroxysmal nocturnal hemoglobinuria. Treatment with warfarin was started but ischemic episodes recurred despite appropriate anticoagulation. Treatment with the complement inhibitor eculizumab was then proposed.

Cutaneous Bronchobiliary Fistula Treated with Tissucol Sealant

Bronchobiliary fistula is a rare and is an uncommon but severe complication of hydatid disease of the liver. Treatment has traditionally been surgical resection, but embolization and stent placement have been described. The invasive method seems to be a key component of patient treatment. We describe a case of a 58-year-old woman who, 25 years before, had undergone surgery for a hydatid cyst. A total cystectomy without previous puncture or parasite extraction was carried out. The lower aspect of the cyst was found to be completely perforated over the biliary duct. During the postoperative course, the patient had subphrenic right-sided pleural effusion and biliary fistula that subsided with medical treatment. Afterward, the patient came to the outpatient area of our hospital complaining of leakage of purulent exudate through the cutaneous opening, pain located on the right hypochondrium radiating to the right hemithorax, malaise, fever, chronic cough, and occasional vomiting of bile. Fistulography revealed an anfractuous cavity communicating with a residual cystic cavity on the right hepatic lobe. We observed communication with the intrahepatic canaliculi. Computed tomographic scan revealed a fistulous tract on the anterior liver border through the abdominal wall. There were no posttreatment complications. The patient is asymptomatic.

Laparoscopic-Assisted Truncal Vagotomy and Gastro-Jejunostomy: Trial of Simplification

Truncal vagotomy and gastro-jejunostomy is an effective procedure for Gastric Outlet Obstruction. The authors' experience with the procedure is presented and an alternative technique for creating the gastro-jejunostomy is described. From January 2005 through June 2007, 18 patients with gastric outlet obstruction secondary to a cicatrizing peptic duodenal ulcer underwent laparoscopic truncal vagotomy and an ante-colic laparoscopic-assisted stapled gastro-jejunostomy. All procedures were completed laparoscopically with a mean operative time of 81.2 +/- 11.1 minutes. Anastomotic leak was encountered in 1 (5.5%) patient and bile vomiting in 2 patients (11%). The mean follow-up duration was 22.8 +/- 9.8 months. None of the patients developed recurrent obstruction. The procedure is feasible, safe, and provides an effective cure for gastric outlet obstruction. The laparoscopic-assisted stapled gastro-jejunostomy reduces the operative time and may reduce the cost of the procedure.

Late-onset volvulus without malrotation in preterm infants

Purpose The aim of the study was to report a new observation of late-onset volvulus without malrotation (VWM) in preterm infants. Methods The study used medical note review of infants with VWM identified at a single regional centre between 1996 and 2007. Results Ten patients were identified. Group 1 includes 4 patients (gestation, 28-38 weeks; median, 32) who presented within 4 days of age (range, 1-4; median, 3). Group 2 includes 6 patients (gestation, 25-33 weeks; median, 27), who presented later (range, 22-57 days; median, 45). Characteristics of group 2 patients included recurrent episodes of abdominal distension and bile vomiting (6/6), long-term continuous positive airway pressure requirement (5/6), and sudden, severe deterioration with acute abdominal signs (6/6). Small bowel volvulus was found at laparotomy requiring resection (30%-70% of total small bowel) and either primary anastomosis (4) or stoma formation (2). All babies survived. Conclusions There appear to be 2 clinical groups with VWM—one presenting within the first few days of life and the other presenting after the first month of life associated with a specific clinical history. This latter group has not been described before.

Bilious vomiting in the newborn: how often is further investigation undertaken?

Background/Purpose Pediatric surgeons consider bile vomiting in the neonate a potential surgical emergency. The reported rate of surgical intervention is 30% to 40%, but as most neonates are born outwith pediatric surgical centers, referral of these babies is at the neonatologists' discretion. The aim of this study was to determine the referral policy of neonatologists in the West of Scotland for a neonate with bile vomiting. Methods Questionnaires were sent to all neonatologists in the West of Scotland to determine the management plan for a neonate with a single bile vomit or repeated bile vomits. Respondents were asked to indicate whether they would advocate postnatal ward observation, admission to the special care baby unit, abdominal x-ray, or upper gastrointestinal contrast study, or refer to pediatric surgeons. Respondents were asked to prioritize these options numerically. Results A return rate of 81% was achieved. Most neonatologists (80%) would admit a neonate with a single bile vomit to the special care baby unit, but more than 50% did not consider an upper gastrointestinal contrast study appropriate. One third felt that pediatric surgical referral is not appropriate for a single bile vomit. In a neonate with persistent bile vomiting, pediatric surgical referral was considered the highest priority. Conclusion Neonatologists use a policy of observation for neonates with a single bile vomit. Those neonates with no further bile vomiting are unlikely to be referred. Pediatric surgeons are not referred a significant proportion of neonates that vomit bile.

Colour of bile vomiting in intestinal obstruction in the newborn: questionnaire study

Colour of bile vomiting in intestinal obstruction in the newborn: questionnaire study

Colour recognition of bile vomiting in the newborn

Colour recognition of bile vomiting in the newborn

Colour of bile vomiting in intestinal obstruction in the newborn: questionnaire study

Objectives To identify the colour that different groups of observers thought represented bile in a newborn's vomit.Design Questionnaires displaying eight colours (pale yellow to dark green).Setting General practices in Glasgow,...