Sudden Pressure Increase Research Articles

A Numerical and Experimental Study of Kick Dynamics at Downhole

The early detection of a kick and mitigation with appropriate well control actions can minimize the risk of a blowout. This paper proposes a downhole monitoring system, and presents a dynamic numerical simulation of a compressible two-phase flow to study the kick dynamics at downhole during drilling operation. This approach enables early kick detection and could lead to the development of potential blowout prevention strategies. A pressure cell that mimics a scaled-down version of a downhole is used to study the dynamics of a compressible two-phase flow. The setup is simulated under boundary conditions that resemble realistic scenarios; special attention is given to the transient period after injecting the influx. The main parameters studied include pressure gradient, raising speed of a gas kick, and volumetric behavior of the gas kick with respect to time. Simulation results exhibit a sudden increase of pressure while the kick enters and volumetric expansion of gas as it flows upward. This improved understanding helps to develop effective well control and blowout prevention strategies. This study confirms the feasibility and usability of an intelligent drill pipe as a tool to monitor well conditions and develop blowout risk management strategies.

Hemorrhagic Valsalva Retinopathy in a Pregnant Woman

Valsalva retinopathy is caused by a sudden increase in intra-thoracic or abdominal pressure, following forced expiration, with mouth and nose closed (Valsalva maneuver). We report a case of Valsalva retinopathy in a pregnant woman. A 36 years old patient, pregnant at 24 weeks of amenorrhea, who consulted for sudden visual acuity decrease of the left eye, evolving since 24 hours after Valsalva maneuvers to calm down her panic and control her breathing. The refraction has demonstrated a decrease of visual acuity in the left eye to “can see a hand moving”, while the visual acuity remained normal in the right eye. Spontaneous evolution was marked by a fast and progressive reduction of hemorrhage and progressive recovery of vision in the left eye. Valsava retinopathy was first described in 1972 by Thomas Duane. Physical activity is usually found before it occurs. Many situations are usually associated to this occurrence among which: pregnancy, vomiting, weightlifting or trauma. Regression of this hemorrhage without sequelae is usual. But sometimes, we need a Nd:Yag laser treatment or surgery to evacuate the blood.

Pars-plana fluid aspiration for positive vitreous cavity pressure in anterior segment surgeries.

Positive vitreous pressure due to misdirection of aqueous or choroidal effusion leads to shallowing of the anterior chamber (AC) before or during anterior segment surgeries. This shallow AC if not addressed makes surgery difficult and increases the risk of surgical complications. Methods to prevent and manage this condition described in literature are not without problems. We describe a minimally invasive technique of passing a 30G needle through the pars-plana to aspirate misdirected fluid from vitreous cavity either as a prophylaxis just before surgery or during it, thereby decreasing positive vitreous pressure. This technique, used in 12 eyes, seems to be effective in patients with angle-closure glaucoma, malignant glaucoma, and per-operative sudden increase in vitreous pressure during surgery. Small-incision surgeries are ideally suited for this procedure. This minimally invasive technique is simple to perform and complications are unlikely to be more than what is seen with intravitreal injections.

Cushing Reflex and Importance during Treatment of Cerebrovascular Diseases via Endovascular Route

Aim: Assessment of the Cushing reflex developing during mechanical thrombectomy in a case presenting with acute ischemic stroke.Case: A 59-year-old male patient had CT angio tests due to speaking disorder and right lateral weakness developing 5 hours earlier. Acute infarctus was observed in the left MCA irrigation area with M1 segment occlusion observed in the left MCA. The decision was made to treat the patient with mechanical thrombectomy and he was transferred to the interventional neuroradiology unit. Under general anesthesia during navigation of the thromboaspiration catheter to the clot localization as the procedure was technically advancing routinely, with sudden development of bradycardia and hypertension the neuroradiology team was warned, and 1 mg IV atropine was administered for bradycardia.Simultaneously contrast material injection through the guide catheter showed the MCA M1 segment had ruptured and extravasation had developed.Conclusion: The Cushing reflex is a situation characterized by bradycardia and hypertension in cerebrovascular events causing sudden intracranial pressure increases. The most common situations observed during treatment of cerebrovascular diseases via the endovascular route is intracranial hemorrhage linked to arterial rupture. Prevention of the mortality and morbidity linked to hemorrhagic complications developing during endovascular treatment is based on early awareness and rapid treatment. Additionally, as extravasation is commonly not observed radiologically, the anesthesia team should be on the alert for the Cushing reflex and when variations of hemodynamic parameters in accordance with the Cushing response are observed, informing the operation team immediately has vital importance.

Amlodipine drug therapeutic failure: a rare case report

Drug Therapeutic failure is a rare condition which is underreported in recent scenario. It is important for the chronic diseases like Hypertension where it could lead to fatal outcome. In our case report elderly male patient taking tablet Amlodipine once daily as antihypertensive medication and had 2 years without any events. Patient came to the emergency department with the complaint of altered sensorium and elevated blood pressure. The mechanism for sudden increase in blood pressure (Decreased Therapeutic Response) in patient with ongoing treatment with amlodipine could be due to sympathetic over activity (e.g. stress), pharmacokinetic variation or counterfeit drug.

Changes of cortical perfusion in the early phase of subarachnoid bleeding in a rat model and the role of intracranial hypertension.

Brain perfusion is reduced early after subarachnoid hemorrhage (SAH) due to intracranial hypertension and early vasospasm. The contribution of these two mechanisms is unknown. By performing a prophylactic decompressive craniectomy (DC) in a rat model of SAH we aimed to study brain perfusion after the component of intracranial hypertension has been eliminated. We used 2x2 factorial design, where rats received either decompressive craniectomy or sham operation followed by injection of 250 microl of blood or normal saline into prechiasmatic cistern. The cortical perfusion has been continually measured by laser speckle-contrast analysis for 30 min. Injection of blood caused a sudden increase of intracranial pressure (ICP) and drop of cerebral perfusion, which returned to baseline within 6 min. DC effectively prevented the rise of ICP, but brain perfusion after SAH was significantly lower and took longer to normalize compared to non-DC animals due to increased cerebral vascular resistance, which lasted throughout 30 min experimental period. Our findings suggest that intracranial hypertension plays dominant role in the very early hypoperfusion after SAH whilst the role of early vasospasm is only minor. Prophylactic DC effectively maintained cerebral perfusion pressure, but worsened cerebral perfusion by increased vascular resistance.

Rumination Syndrome: The Forgotten Offender

Rumination syndrome is an under-diagnosed and not well-understood condition. It's a repetitive and effortless habit that becomes a subconscious process, which affects children and adults that are developmentally challenged as well as healthy patients of all ages. It carries social stigmata and impacts one's health. We describe a case of a middle-aged woman suffering from this for majority of her life and once successfully diagnosed, she underwent biofeedback therapy and diaphragmatic breathing technique with remarkable improvement in her quality of life. A 68 year-old female with history of GERD presented with chronic regurgitations for > 48 years with re-mastication afterwards, negatively impacting her social life. Extensive work up was unremarkable including upper endoscopy, barium esophagram and gastric emptying study. Esophageal manometry showed normal contraction amplitude and LES profile. 24-hour pH-impedance reflux testing on acid suppression showed poor gastric acid control and slightly abnormal upright acid exposure (1.6%). One-hour high-resolution manometry-impedance study after consuming a provocative meal, with advancing the catheter distally into the proximal stomach, revealed total of 39 episodes of regurgitation (Figure 1). Episodes were preceded by increase in intra-gastric pressure (>30 mmHg), and were followed immediately by normal swallows to clear up the regurgitated food and were typical for rumination syndrome. Biofeedback was implemented, and diaphragmatic breathing technique was used as adjunctive modality for therapy. 6 months later, she had significant improvement in her social life with remarkable relief of symptoms. A Likert scale was used to quantify symptoms reduction (Figure 2). Rumination syndrome is often misdiagnosed for other upper gastrointestinal disorders (GERD, functional dyspepsia, eating disorders like bulimia, gastroparesis and chronic intestinal pseudo-obstruction). It involves involuntary increase in gastric pressure followed by opening of LES and increase in the intra-esophageal pressure to the same extent as gastric (common-cavity phenomenon). Rumination syndrome can be diagnosed with clinical symptomatology according to Rome IV criteria (Figure 3). Combined esophageal manometry-impedance testing is helpful in confirming the diagnosis. Biofeedback and behavioral modification therapy with diaphragmatic breathing proved to be useful in management of this chronic condition.Figure: High-resolution esophageal impedance-manometry showing sudden increase in intra-gastric and intra-esophageal pressure followed by a normal swallow to clear the regurgitated food (Left-hand side). Conventional manometry shows increase intra-gastric and esophageal pressure followed by normal swallow (Right-hand side).Figure: Patient's symptom improvement on Likert scale 1, 2 and 5 months through treatment. On a scale from 0-5, where 0 represents no symptoms and 5 represents severe symptoms, patient had 50% decrease in regurgitation, resolution of heartburn, 75% decrease in belching, 2/3 decrease in acid taste in mouth and resolution on bloating sensation with use of biofeedback and diaphragmatic breathing.Figure: Rome IV criteria for Rumination Syndrome

Experimental and modelling characterisation of adjustable hollow Micro-needle delivery systems

BackgroundHollow micro-needles have been used increasingly less in practice because the infusion into the skin is limited by the tissue resistance to flow. The relationship between the infusion flow rate and tissue resistance pressure is not clear. MethodsA custom-made, hollow micro-needle system was used in this study. The driving force and infusion flow rate were measured using a force transducer attached to an infusion pump. Evans blue dye was injected into the air, polyacrylamide gel and in-vivo mouse skin at different flow rates. Two different micro-needle lengths were used for in-vivo infusion into the mouse. A model was derived to calculate the driving force of the micro-needle infusion into the air, and the results were compared to experimental data. ResultsThe calculated driving forces match the experimental results with different infusion flow rates. The pressure loss throughout the micro-needle delivery system was found to be two orders smaller than the resistance pressure inside the gel and mouse skin, and the resistance pressure increased with increasing flow rate. A portion of liquid backflow was observed when the flow rate was relatively larger, and the backflow was associated with a sudden larger increase in resistance pressure at a higher flow rate. ConclusionsThe current micro-needle delivery system is capable of administering liquid into the mouse skin at a flow rate of up to 0.15 ml/min, without causing significant backflow on the surface. The resistance pressure increases with increasing flow rate, causing infusion restriction at higher flow rates.

CLINICAL CHARACTERISTICS OF TGA ACCORDING TO HIPPOCAMPAL LESIONS: EXPERIENCE OF 212 CASES

Transient global amnesia (TGA) is a rare clinical diagnosis characterized by the sudden onset of anterograde with repetitive questioning, and lesser degree of retrograde amnesia, lasting up to 24 hours, without compromise of other neurologic functions. Several pathophysiologic mechanisms have been proposed, but none of them has been proved to explain all cases of TGA consistently. We reviewed data of TGA patients who visited Chungnam National University Hospital from 2010, January to 2017, January. A total of 324 patients under the impression of TGA, 212 patients were met TGA criteria and performed brain magnetic resonance imaging and neuropsychological tests. We compared the clinical and neuropsychological characteristics of TGA patients according to presence or absence of the hippocampal lesion on diffuse weighted images (DWI+ vs. DWI-). Ninety two patients (43.3%) with TGA had the visible hippocampal lesions on the DWIs and the most number of lesions (63.8%) were found in 12 to 48 hours after the onset of TGA. One hundred thirty five patients with TGA (64.8%) had various precipitating factors before the onset of TGA symptoms. The most distinguishing precipitating factor between the DWI+ and DWI- groups was emotional events such as crying and angry. The incidence of physical activities as a precipitating factor for TGA occurrence was increased in the spring and fall. None of neuroimaging features such as numbers of lacunae, degree of temporal lobe atrophy, or white matter hyperintensity were different, depending on the hippocampal lesions. The patients with right hippocampal lesion showed lower function of non-verbal short-term memory on RCFT but no difference found on the verbal memory function by hippocampal lesion location. Although hippocampal lesion is not always found in patients with TGA, it could give some explanations for understanding pathophysiologic mechanisms of TGA. Uncontrollable emotion or unusual strong physical activities may be associated with central venous congestion due to sudden increase of central pressure, triggering TGA onset.

Urinary Incontinence and Overactive Bladder Syndrome

Urinary incontinence falls into two broad categories: stress incontinence and urge incontinence. Stress urinary incontinence occurs when urethral closure pressure cannot increase sufficiently to compensate for a sudden increase in intra-abdominal pressure, as from a cough or Valsalva maneuver. Urge urinary incontinence occurs when an unintended bladder contraction creates an insuppressible urge to void, leading to urinary leakage. When women have signs and/or symptoms of both stress and urge incontinence, it is referred to as mixed urinary incontinence. Overactive bladder syndrome is defined by the Standardization Subcommittee of the International Continence Society (ICS) as urinary urgency, with or without urge incontinence and usually with frequency and nocturia. Nocturia, which is often associated with urinary frequency, is defined as a need to urinate that awakens the person during the night. This chapter discusses the epidemiology and physiology of urinary incontinence and overactive bladder syndrome in women, as well as diagnosis and treatment. Tables list foods and beverages that may cause urinary frequency and urgency; features of urge incontinence, stress incontinence, and mixed incontinence; American Urologic Association (AUA) guidelines regarding level of evidence and indications for adult urodynamics; and currently available antimuscarinic drugs and their dosages, selectivity, efficacy, and side effects. Figures depict the journal of someone with mixed incontinence, a typical urodynamics suite, a urodynamic study of someone with detrusor overactivity, incontinence pessaries, and transobturator and retropubic slings. This review contains 5 figures, 5 tables, and 44 references.

Monitoring the stability of tailings dam walls with ambient seismic noise

Tailings dams are massive structures designed to contain the waste slurry remaining after processing ore at open pit and underground mines. These structures fail far more regularly than normal water-storage dams. In recent years, catastrophic tailings dam failures have occurred, causing significant damage to the environment and even loss of life. To mitigate these catastrophic events in the future, there is an urgent need to develop cost-effective methods to monitor the structural stability of these constructions over time. The lack of current cost-effective monitoring methods prompted us to investigate whether ambient seismic noise can be used to detect internal changes in a tailings dam wall during a period of heavy rainfall. We recorded three weeks of continuous seismic data with 10 short-period geophones at a tailings dam in Tasmania, Australia. Seismic interferometry was used on ambient noise to create virtual seismic sources. With these virtual source signals, small changes in seismic velocity were measured daily and compared to rainfall, seepage flow rates, and fluid pore pressure. The observed velocity changes were driven by fluid saturation, ground water level, increased loading from increased dam water level, and a sudden increase in fluid pore pressure in a section of the dam wall. The results suggest that this relatively inexpensive method can be used to monitor and locate small changes in the interior of the tailings dam wall, providing a valuable tool to remotely monitor the structural stability of tailings dam walls over time.

Pleural Effusions and Pneumothoraces.

1. Katherine Cashen, DO* 2. Tara L. Petersen, MD† 1. *Department of Pediatrics, Children's Hospital of Michigan/Wayne State University School of Medicine, Detroit, MI 2. †Division of Critical Care, Department of Pediatrics, The Children’s Hospital of Wisconsin/The Medical College of Wisconsin, Milwaukee, WI * Abbreviations: BTS: : British Thoracic Society CHF: : congestive heart failure CT: : computed tomography VATS: : video-assisted thoracoscopic surgery 1. Clinicians should be aware of the causes and clinical presentation of pleural effusions and pneumothoraces. 2. Clinicians should understand the current role of diagnostic tests, imaging modalities, and timing of minimally invasive treatments. After completing this article, readers should be able to: 1. Describe the pathogenesis of pleural fluid accumulation. 2. Identify the most likely causes of pleural effusion and pneumothorax. 3. Understand the basic clinical presentation, diagnostic tests, and management of pleural effusions and pneumothoraces. 4. Differentiate between transudative and exudative pleural effusions. 5. Understand the natural history of spontaneous pneumothorax. The pleural space is created by the parietal and visceral pleura that line the chest wall and the lung surface, respectively. Normally, only a small amount (0.3 mL/kg) of hypotonic fluid is present within the pleural space due to homeostatic balances in physiologic fluid production and absorption. Various infectious and noninfectious processes can lead to pathologic filling of the pleural space with fluid (effusion) or air (pneumothorax). Such pathologic changes create a true space that can interfere with normal lung mechanics and, in severe cases, cardiac function. Although much less common in pediatric than adult populations, pleural effusions and pneumothoraces in both groups can lead to substantial complications, resulting in significant morbidity and mortality if unrecognized or untreated. Overall, the cause of pleural effusions and pneumothoraces differs in children compared to adults. In adults, congestive heart failure (CHF) and malignancy account for a substantial number of pleural effusions, but these are uncommon causes in children. Infectious pleural effusions in the setting of pneumonia (parapneumonic effusions) remain the most common cause of effusions in both children and adults. Unlike the adult population, children experience spontaneous …

Design Construction and Testing of a Petroleum Product Storage Tank 10 Million Litre Capacity

The purpose of this paper is to design a 10 million litre capacity petroleum storage tank for use in the oil industry in Nigeria with a view to overcoming the challenges associated with the loss of product due to evaporation. The tank having diameter and height of 27.4m and 17.5m respectively was designed to have two relief valves; a primary valve which would ensure that the product vapour pressure within high-level (h2) in meters of the storage tank does not exceed the minimum acceptable pressure. The second relief valve is designed to relief due to a sudden increase in pressure as a result of a possible fire in the tank. To this end, the design made reference to the American Petroleum Institute Manual 650 (12th Edition) as a guide. Some fundamental considerations include tank shape, height, diameter and materials used. A corrosion allowance of 3mm was also considered.

Design Construction and Testing of a Petroleum Product Storage Tank 10 Million Litre Capacity

The purpose of this paper is to design a 10 million litre capacity petroleum storage tank for use in the oil industry in Nigeria with a view to overcoming the challenges associated with the loss of product due to evaporation. The tank having diameter and height of 27.4m and 17.5m respectively was designed to have two relief valves; a primary valve which would ensure that the product vapour pressure within high-level (h2) in meters of the storage tank does not exceed the minimum acceptable pressure. The second relief valve is designed to relief due to a sudden increase in pressure as a result of a possible fire in the tank. To this end, the design made reference to the American Petroleum Institute Manual 650 (12th Edition) as a guide. Some fundamental considerations include tank shape, height, diameter and materials used. A corrosion allowance of 3mm was also considered.

Microscopic Evolution of Laboratory Volcanic Hybrid Earthquakes

Characterizing the interaction between fluids and microscopic defects is one of the long-standing challenges in understanding a broad range of cracking processes, in part because they are so difficult to study experimentally. We address this issue by reexamining records of emitted acoustic phonon events during rock mechanics experiments under wet and dry conditions. The frequency spectrum of these events provides direct information regarding the state of the system. Such events are typically subdivided into high frequency (HF) and low frequency (LF) events, whereas intermediate “Hybrid” events, have HF onsets followed by LF ringing. At a larger scale in volcanic terranes, hybrid events are used empirically to predict eruptions, but their ambiguous physical origin limits their diagnostic use. By studying acoustic phonon emissions from individual microcracking events we show that the onset of a secondary instability–related to the transition from HF to LF–occurs during the fast equilibration phase of the system, leading to sudden increase of fluid pressure in the process zone. As a result of this squeezing process, a secondary instability akin to the LF event occurs. This mechanism is consistent with observations of hybrid earthquakes.

Subcutaneous Emphysema and Pneumomediastinum in 2 Years Old Children with Pierre Robin Syndrome: Multi-Disciplinary Management in an Emergency Department

Spontaneous pneumomediastinum (SPM) is an uncommon disease defined by the presence of free air in the mediastinal cavity. Its pathogenesis is characterized by all the processes that cause a sudden increase of intrathoracic pressure. Triggering factors are: lower airway infections, asthma, esophageal rupture, foreign body aspiration and diabetic ketoacidosis. When a cause is not found, SPM is defined idiopathic. The abnormal presence of air in mediastinum can cause subcutaneous emphysema (SE) in the neck and upper part of the thorax. The aim of this report was to describe a patient with an underlying genetic disorder (Pierre Robin syndrome) and SPM with consequent SE. A multidisciplinary approach in our Accident and Emergency department was important for the right management.

Quadruple point determination in carbon dioxide hydrate forming system

The quadruple point in carbon dioxide hydrate forming system, ice + water-rich liquid + hydrate + carbon dioxide-rich gas four-phase equilibrium condition, has been determined based on supercooled water-rich liquid + hydrate + carbon dioxide-rich gas and water-rich liquid + hydrate + carbon dioxide-rich gas three-phase equilibrium conditions measured in this study combined with ice + hydrate + carbon dioxide-rich gas three-phase equilibrium conditions reported in the literature (K. Yasuda, R. Ohmura, J. Chem. Eng. Data 53 (2008) 2182–2188). The intersection of the three types of the three-phase equilibrium conditions was used to determine the quadruple point. The three-phase equilibrium condition experiments were performed at temperatures between 269.45 K and 275.75 K, and at pressures between 0.825 MPa and 1.708 MPa. The determined p–T condition at quadruple point was T = 271.6 ± 0.2 K and p = 1.04 ± 0.02 MPa. It was also observed that the freezing of supercooled water during some experimental runs performed below the quadruple point temperature, which causes sudden increase in both pressure and temperature.

CFD simulation of reverse water-hammer induced by collapse of draft-tube cavity in a model pump-turbine during runaway process

This paper reports the preliminary progress in the CFD simulation of the reverse water-hammer induced by the collapse of a draft-tube cavity in a model pump-turbine during the runaway process. Firstly, the Fluent customized 1D-3D coupling model for hydraulic transients and the Schnerr & Sauer cavitation model for cavity development are introduced. Then, the methods are validated by simulating the benchmark reverse water-hammer in a long pipe caused by a valve instant closure. The simulated head history at the valve agrees well with the measured data in literature. After that, the more complicated reverse water-hammer in the draft-tube of a runaway model pump-turbine, which is installed in a model pumped-storage power plant, is simulated. The dynamic processes of a vapor cavity, from generation, expansion, shrink to collapse, are shown. After the cavity collapsed, a sudden increase of pressure can be evidently observed. The process is featured by a locally expending and collapsing vapor cavity that is around the runner cone, which is different from the conventional recognition of violent water- column separation. This work reveals the possibility for simulating the reverse water-hammer phenomenon in turbines by 3D CFD.

Dayside magnetospheric and ionospheric responses to solar wind pressure increase: Multispacecraft and ground observations

AbstractWe provide in situ observations of the transient phenomena in the dayside magnetosphere during the preliminary impulse (PI) and main impulse (MI) event on 30 September 2008. The PI and MI geomagnetic signals are induced by twin traveling convection vortices with opposite polarities in the equivalent ionospheric currents due to a sudden increase of the solar wind dynamic pressure. The two PI‐associated ionospheric current vortices centered at ~07 magnetic local time (MLT), 67° magnetic latitude (MLAT) in the dawnside and ~14 MLT, 73°MLAT in the duskside, respectively. The dawnside MI current vortex centered at ~68° MLAT and 6 MLT, while the duskside vortex center was traveling poleward from ~67° MLAT to ~75° MLAT at a speed of ~5.6–7.4 km/s around 14 MLT. It is found that both dawnside PI‐ and MI‐related current vortices were azimuthally seen up to 4 MLT. Following the magnetosphere sudden impulse, a clockwise flow vortex with a radial scale larger than 3 RE, associated with positive field‐aligned current (FAC), was observed by Time History of Events and Macroscale Interactions during Substorms (THEMIS) spacecraft in the outer dayside magnetosphere. The flow vortex expanded and traveled tailward in the magnetosphere, also being reproduced with global MHD simulations. Based on both observation and simulation technique, we show that the MI‐related FACs are correlated with the large‐scale flow vortex. The PI FACs are partially provided by the mode conversion of fast mode waves into the Alfvén waves near the equatorial plane, while most of it may be generated at a higher‐latitude region in the magnetosphere.

Wilkie’s Syndrome Causing Acute Gastric Necrosis

SESSION TITLE: Student/Resident Case Report Poster - Critical Care II SESSION TYPE: Student/Resident Case Report Poster PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM INTRODUCTION: Superior mesenteric artery (SMA) syndrome or Wilkie’s syndrome is compression of the third part of the duodenum between the SMA & abdominal aorta. This compression can lead to acute gastric dilation and necrosis of the stomach. SMA syndrome leading to acute gastric dilation is rare and necrosis of the stomach; an organ with extensive collateral blood supply can be fatal. CASE PRESENTATION: A 26-year-old male with a history of type I diabetes presented with vomiting and abdominal pain of 1 day. Exam was remarkable for BP of 93/60 mm Hg & HR of 106. Patient was cachectic & in distress, abdomen was distended with diffuse tenderness. Labs revealed Hb of 8, leucocytosis of 13000 and lactate of 3.6. IV fluid bolus & antibiotics were started. 6 hours later he had emesis of black fluid with development of shock requiring vasopressors, intubation for acute respiratory failure and intensive care. Abdominal X-ray showed a giant lucency, thought to be the distended stomach. NG tube inserted returned 2.4 liters of black fluid. CT abdomen showed a distended gastric & esophageal lumen with a transition point between the 2nd and 3rd part of duodenum. EGD showed deep ulcerations over the stomach and eschar formation. Upper GI series confirmed SMA syndrome. As patient continued to be in septic shock ,surgery was deferred. Explorative laparotomy done on Day 9 of admission, ended in total gastrectomy and esophago-jejunostomy & a feeding jejunostomy. Post procedure patient had a prolonged recovery. DISCUSSION: SMA syndrome occurs in hyper catabolic states such as malignancy, burns and anorexia nervosa. Acute gastric dilation results in sudden increase in intraluminal gastric pressure and gastric venous insufficiency causing gastric necrosis.1 SMA syndrome is initially treated conservatively with gastric decompression, correction of electrolytes & nutritional support.2 Surgical intervention is needed if there is no resolution or if signs of sepsis develop. In our patient the diagnosis and later the surgical intervention was delayed resulting in increased morbidity. CONCLUSIONS: As the presentation is often non-specific for the above-described entities a high index of suspicion & early abdominal imaging with a KUB, followed by a CT abdomen, if required is the key to diagnosis. Early diagnosis is imperative to prevent onset of necrosis & once identified, early surgical intervention can salvage viable bowel. Reference #1: Steen S, Lamont J, Petrey L. Acute gastric dilation and ischemia secondary to small bowel obstruction. Proc (Bayl Univ Med Cent). 2008 Jan;21(1):15-7. Reference #2: Merrett ND, Wilson RB, Cosman P, Biankin A V. Superior Mesenteric Artery Syndrome: Diagnosis and Treatment Strategies. J Gastrointest Surg. 2009 Feb 23;13(2):287-92. DISCLOSURE: The following authors have nothing to disclose: Nisha Ajit, Kovid Trivedi, Robert Walter No Product/Research Disclosure Information