Hemorrhagic complications during EUS-guided pseudocyst drainage can occur, because the vessels on the internal wall of the pseudocyst might be compressed by the fluid and thus not visible on color Doppler or even power Doppler EUS.
Laparoscopic Liver Resection : What to do and not do
Chirurgie laparoscopique du foie : indications et limites actuelles
Pr Daniel CHERQUI
Journées du Centre Hépato-Biliaire - JCHB 2019
Journées de Chirurgie
Bile duct injury:How safe is emergency laparoscopic cholecystectomy?KETAN VAGHOLKAR
laparoscopic cholecystectomy has become the gold standard . But its safety in acute cholecystitis is debatable. The traditional dictum to wait for 6 weeks before contemplating removal of the gall bladder still remains the safest option rather than removing the gall bladder on an emergency basis and heightening the chances of bile duuct injury leading to a surgical disaster.The presentation outlines the evaluation and management of bile duct injuries.
Venous reflux occurs when valves in the veins fail, allowing blood to flow backwards and pool in the legs. This leads to increased venous pressure and microcirculatory damage over time. The pathology involves a fibrin cuff forming from blood cells trapped in the tissues by high pressure, restricting oxygen flow and causing edema, skin changes, and eventually ulcers. Reflux is transmitted from deep to superficial veins through perforating veins, supporting the water hammer effect theory of venous ulcer formation. Chronic venous insufficiency has two components - venous reflux and obstruction - disrupting the normal one-way flow of blood from the feet back to the heart.
Bile duct injuries are a serious complication of cholecystectomy that can occur even in the hands of experienced surgeons. They are classified based on the type and extent of injury. Investigation involves imaging like MRCP or ERCP to determine the nature and location of the injury. Management depends on the type of injury but may involve drainage, endoscopic stenting, or surgical reconstruction like hepaticojejunostomy. Vasculobiliary injuries that also involve blood vessels add complexity and affect treatment options. Preventive measures include careful dissection and confirmation of biliary and vascular anatomy.
This document summarizes information presented by the Surgical Club of Red Sea University on the topic of burns. It discusses the function of skin, epidemiology of burns including risk factors, etiology and types of burns. It also covers the pathophysiology and pathology of burns including zones of injury and methods of assessing burn extent. Management of burns is outlined including first aid, indications for admission, fluid resuscitation, wound care, grafting and other reconstructive procedures. Complications, prognosis and references are also summarized.
This document discusses the radiologic features of blunt liver trauma seen on CT imaging. It describes various injuries including lacerations, hematomas, active hemorrhage, venous injuries, and periportal low attenuation. CT is also useful for assessing complications such as delayed hemorrhage, hepatic abscess, pseudoaneurysms, and biliary issues. Specific cases are presented to illustrate different grades of injury on the AAST scale from I to V, as well as associated findings and management strategies.
The document discusses different techniques for aortic valve-sparing operations, including the remodeling technique and the reimplantation technique. It provides details on how each technique is performed surgically and discusses findings from studies comparing the techniques. The main points are:
1) The remodeling technique preserves some aortic root distensibility but the reimplantation technique causes higher pressure gradients due to a more rigid fixation of the valve.
2) Bending deformation of the valve leaflets is higher for both techniques compared to native aortic roots, due to the use of synthetic graft material.
3) Aortic root distensibility decreases for both techniques compared to native roots, with less distensibility observed with
Laparoscopic Liver Resection : What to do and not do
Chirurgie laparoscopique du foie : indications et limites actuelles
Pr Daniel CHERQUI
Journées du Centre Hépato-Biliaire - JCHB 2019
Journées de Chirurgie
Bile duct injury:How safe is emergency laparoscopic cholecystectomy?KETAN VAGHOLKAR
laparoscopic cholecystectomy has become the gold standard . But its safety in acute cholecystitis is debatable. The traditional dictum to wait for 6 weeks before contemplating removal of the gall bladder still remains the safest option rather than removing the gall bladder on an emergency basis and heightening the chances of bile duuct injury leading to a surgical disaster.The presentation outlines the evaluation and management of bile duct injuries.
Venous reflux occurs when valves in the veins fail, allowing blood to flow backwards and pool in the legs. This leads to increased venous pressure and microcirculatory damage over time. The pathology involves a fibrin cuff forming from blood cells trapped in the tissues by high pressure, restricting oxygen flow and causing edema, skin changes, and eventually ulcers. Reflux is transmitted from deep to superficial veins through perforating veins, supporting the water hammer effect theory of venous ulcer formation. Chronic venous insufficiency has two components - venous reflux and obstruction - disrupting the normal one-way flow of blood from the feet back to the heart.
Bile duct injuries are a serious complication of cholecystectomy that can occur even in the hands of experienced surgeons. They are classified based on the type and extent of injury. Investigation involves imaging like MRCP or ERCP to determine the nature and location of the injury. Management depends on the type of injury but may involve drainage, endoscopic stenting, or surgical reconstruction like hepaticojejunostomy. Vasculobiliary injuries that also involve blood vessels add complexity and affect treatment options. Preventive measures include careful dissection and confirmation of biliary and vascular anatomy.
This document summarizes information presented by the Surgical Club of Red Sea University on the topic of burns. It discusses the function of skin, epidemiology of burns including risk factors, etiology and types of burns. It also covers the pathophysiology and pathology of burns including zones of injury and methods of assessing burn extent. Management of burns is outlined including first aid, indications for admission, fluid resuscitation, wound care, grafting and other reconstructive procedures. Complications, prognosis and references are also summarized.
This document discusses the radiologic features of blunt liver trauma seen on CT imaging. It describes various injuries including lacerations, hematomas, active hemorrhage, venous injuries, and periportal low attenuation. CT is also useful for assessing complications such as delayed hemorrhage, hepatic abscess, pseudoaneurysms, and biliary issues. Specific cases are presented to illustrate different grades of injury on the AAST scale from I to V, as well as associated findings and management strategies.
The document discusses different techniques for aortic valve-sparing operations, including the remodeling technique and the reimplantation technique. It provides details on how each technique is performed surgically and discusses findings from studies comparing the techniques. The main points are:
1) The remodeling technique preserves some aortic root distensibility but the reimplantation technique causes higher pressure gradients due to a more rigid fixation of the valve.
2) Bending deformation of the valve leaflets is higher for both techniques compared to native aortic roots, due to the use of synthetic graft material.
3) Aortic root distensibility decreases for both techniques compared to native roots, with less distensibility observed with
Indications of renal replacement therapyBimal khadka
1. The document discusses the history of hemodialysis and kidney transplantation, beginning with the first hemodialysis treatment in 1924 and the first documented kidney transplant in 1950 in the US.
2. It then covers the development of dialysis therapy and renal replacement therapy, including the first successful kidney transplant between identical twins in 1954.
3. Key aspects of dialysis therapy methods like hemodialysis and peritoneal dialysis are described, along with indications for starting renal replacement therapy and complications of transplantation.
This document provides an overview of basic principles of liver resection, including:
- A brief history of liver resection and techniques like hepatic inflow occlusion.
- Concepts of liver regeneration, surgical anatomy, and terminology as described by Couinaud.
- Surgical techniques for liver transection including finger fracture, water jet, CUSA, Ligasure, and vascular staplers.
- Methods of vascular control during resection like Pringle maneuver, liver hanging maneuver, and total hepatic vascular exclusion.
- Postoperative management considerations like fluid/electrolyte balance, nutrition, pain control, and monitoring for liver failure.
Fluid, electrolytes, and acid base balanceAmar Yahia
The document discusses fluid, electrolyte, and acid-base balance. It describes the composition of body fluid compartments, including total body water, intracellular water, extracellular water, plasma, and interstitial fluid. It discusses third space fluids and the osmolality of body fluids. Electrolytes such as sodium, potassium, calcium, magnesium, and chloride are described along with their general functions. Water imbalance in the form of water loss or excess is covered. Sodium and potassium metabolism and balance is explained in detail, including causes and treatment of deficiencies and excesses.
This document summarizes several clinical trials comparing on-pump coronary artery bypass grafting (CABG) to off-pump CABG. The CORONARY trial found no difference in mortality at 1 year between on and off-pump, but a slightly higher rate of revascularization with off-pump. The ROOBY trial found higher mortality at 5 years with off-pump compared to on-pump. The DOORS trial found better graft patency rates with on-pump (86%) than off-pump (76%). Trials like GOPCABE and SMART found similar outcomes between on and off-pump techniques. The PROMOTE trial found no significant difference in graft patency rates at 3 months between techniques
Acute SMV thrombosis was described in a document that discussed:
1. It remains a life-threatening condition with high mortality despite advances in treatment.
2. It most commonly involves the superior mesenteric vein and is usually secondary to conditions that increase risk of thrombosis.
3. Presentation can be non-specific with abdominal pain but imaging such as CT can clearly identify thrombosis.
1. Liver injuries are commonly caused by blunt or penetrating abdominal trauma. The right lobe of the liver is most frequently injured.
2. Liver injuries are graded from I to VI based on severity. Grade I injuries involve small lacerations while grade VI involve major vascular injuries.
3. Most liver injuries can now be managed non-operatively with techniques like angiography, embolization, and close monitoring. Operative management is reserved for higher grade injuries or those with ongoing bleeding.
This presentation is all about patient prosthetic mismatch.what is PPM?.
Diameters of heart valve
Effective orifice area of different heart valves
How to avoid PPM
How to manage increased gradients across the heart valve
1. The patient presented with right upper quadrant pain 6 months after liver transplantation. Imaging showed a 1 cm pseudoaneurysm arising from the hepatic artery.
2. Due to the tortuosity of the hepatic artery and pseudoaneurysm, endovascular treatment was not possible. The patient underwent surgery to resect the pseudoaneurysm and reconstruct the hepatic artery.
3. At surgery, the pseudoaneurysm was larger than imaging showed, at 2x1.5 cm. It was successfully resected and the hepatic artery was reconstructed with an interrupted suture. The patient had an uneventful recovery.
Management of liver trauma in adults, 2018, by R. LuneviciusRaimundas Lunevicius
1) The document discusses the management of liver trauma in adults, including classifications of liver injuries, principles of management, and case examples.
2) The most important factors in management are the patient's physiology and response to resuscitation, in addition to the anatomical details of the injury seen on CT scan.
3) Most patients with grades I-III injuries can be managed conservatively with observation and follow-up imaging, while grade IV injuries or unstable patients often require surgery.
The document discusses the use of extracorporeal membrane oxygenation (ECMO) as a treatment for acute respiratory distress syndrome (ARDS). It summarizes that ECMO can act as a bridge to allow the lungs to heal, but comes with risks of bleeding and other complications. While some early trials did not find benefit, more recent evidence from the CESAR trial in the UK showed reduced mortality for ARDS patients who received ECMO support at a specialized center, along with protocolized lung-protective ventilation. Further research is still needed to identify patient selection criteria and standardized protocols.
1. Extracorporeal membrane oxygenation (ECMO) and continuous renal replacement therapy (CRRT) are important life support therapies used in intensive care units.
2. ECMO uses an external circuit to oxygenate blood and remove carbon dioxide, functioning as a bridge to recovery, transplant, or decision. CRRT slowly removes waste and fluid from the blood of patients with kidney failure or injury.
3. The document discusses the principles, indications, techniques, and complications of ECMO and CRRT, highlighting their roles in supporting critically ill patients with cardiac, respiratory, or renal issues.
The liver is frequently injured in abdominal trauma due to its location and size. Most liver injuries can be managed non-operatively through observation, though some require procedures to control bleeding. The severity of injury is graded on a scale of I to VI. For blunt trauma patients who are hemodynamically stable without ongoing bleeding, non-operative management is preferred with monitoring and CT scans. Surgical management is used for unstable patients or those with significant bleeding, and focuses on controlling bleeding through sutures, packing, or clamping blood vessels.
The assistant stands on the opposite side of the table from the surgeon.
Incision: A flank incision is made over the 11th rib extending from the midaxillary line to the
costal margin. The 11th rib is not routinely resected.
DEPT OF UROLOGY, KMC AND GRH, CHENNAI 38
The subcutaneous tissue and external oblique muscle are divided in line with the skin incision.
The internal oblique and transversus abdominis muscles are then divided in the same plane.
The retroperitoneal space is entered by incising the transversalis fascia.
The peritoneum is identified and incised longitudinally along the lateral
Early degeneration of a bioprosthetic mitral valve complicated by a large lef...pascal Pascal, Richard
This case report describes a 71-year-old man who presented with symptomatic early degeneration of a bioprosthetic mitral valve replacement complicated by a large left atrial thrombus. Transesophageal echocardiography revealed severe calcification and stenosis of the bioprosthetic valve as well as a thrombus in the left atrium. The patient underwent mechanical mitral valve replacement and left atrial thrombectomy. Calcium supplementation required for the patient's prior parathyroidectomy may have contributed to early bioprosthetic valve deterioration. Despite anticoagulation, the large thrombus formed due to left atrial stasis from mitral stenosis.
1) Liver trauma is the second most common organ injured in blunt abdominal trauma and the most common injured in penetrating trauma, occurring in 1-8% of patients with multiple blunt trauma.
2) The liver is susceptible to injury due to its size, friable parenchyma, thin capsule, and fixed position near the ribs and spine.
3) Liver injuries are classified based on the mechanism of injury, type and degree of damage, localization within liver lobes/segments, and whether associated vessels or bile ducts are damaged. Grades I-II are minor injuries while Grades III-V require surgical intervention and Grade VI is incompatible with survival.
This document summarizes the surgical technique and complications of central venous catheters for hemodialysis. It discusses the basic concepts, pre-operative evaluation including imaging of central veins, catheter insertion technique, and perioperative and long-term care and complications. The best site for catheter placement is the right internal jugular vein to minimize risks of kinking and central vein stenosis. Ultrasound and fluoroscopy guidance are recommended for accurate placement and tunneling of cuffed catheters. Major perioperative risks include pneumothorax, hemothorax, and nerve injury, while long-term complications consist of infection, thrombosis, stenosis, and catheter malfunction.
The liver is the second most commonly injured organ in blunt abdominal trauma and the most commonly injured in penetrating abdominal trauma. Non-operative management of liver injuries is now the standard of care for hemodynamically stable patients and has a success rate of over 85%, even for high-grade injuries. Failure of non-operative management is usually due to other intra-abdominal injuries rather than the liver injury itself. Operative intervention is indicated for hemodynamically unstable patients or those who fail non-operative management.
Bile Duct Injury and Post Cholecystectomy Biliary StrictureArifuzzaman Shehab
Bile duct injuries are a devastating complication of gallbladder surgery that can have tremendous physical and mental effects on both surgeons and patients. Early recognition within 72 hours allows for minimal inflammation and the highest chance of successful repair. Diagnosis involves signs of abdominal pain and jaundice along with imaging and blood tests showing bile leakage and liver dysfunction. Management depends on the severity and location of the injury, ranging from endoscopic stenting to immediate surgical repair.
- Mesenteric venous thrombosis is an uncommon disease that involves thrombosis of the mesenteric veins with risks including obesity, surgery, and inflammatory bowel disease.
- Patients typically present with diffuse abdominal pain, nausea, diarrhea, or gastrointestinal bleeding. Diagnosis involves blood tests, imaging like CT scans showing dilated bowel loops and ascites, and exclusion of other causes.
- Treatment depends on the severity and includes anticoagulation, bowel rest, thrombolysis, endovascular procedures, and potentially bowel resection surgery. With treatment, mortality rates are around 20-30% with 70% 5-year survival. Lifelong anticoagulation is usually recommended.
Severe bleeding can occur from arteries, veins, or capillaries and cause death within minutes if not treated. Direct pressure, elevation, and digital pressure are emergency treatments for severe bleeding. Direct pressure involves pressing a sterile dressing firmly over the wound for 10-15 minutes until bleeding stops. Elevation above the heart slows blood flow and speeds clotting. Digital pressure is applied at pressure points on bones near arteries to control blood flow and must only be used briefly as an addition to direct pressure and elevation.
PREVIEW OF EMT/EMR BLEEDING POWERPOINT TRAINING PRESENTATIONBruce Vincent
Describes the care of the patient with internal and external bleeding. Estimated teaching time 2 hours. Meets or exceeds current US DOT NHTSA 2009 requirements.
Indications of renal replacement therapyBimal khadka
1. The document discusses the history of hemodialysis and kidney transplantation, beginning with the first hemodialysis treatment in 1924 and the first documented kidney transplant in 1950 in the US.
2. It then covers the development of dialysis therapy and renal replacement therapy, including the first successful kidney transplant between identical twins in 1954.
3. Key aspects of dialysis therapy methods like hemodialysis and peritoneal dialysis are described, along with indications for starting renal replacement therapy and complications of transplantation.
This document provides an overview of basic principles of liver resection, including:
- A brief history of liver resection and techniques like hepatic inflow occlusion.
- Concepts of liver regeneration, surgical anatomy, and terminology as described by Couinaud.
- Surgical techniques for liver transection including finger fracture, water jet, CUSA, Ligasure, and vascular staplers.
- Methods of vascular control during resection like Pringle maneuver, liver hanging maneuver, and total hepatic vascular exclusion.
- Postoperative management considerations like fluid/electrolyte balance, nutrition, pain control, and monitoring for liver failure.
Fluid, electrolytes, and acid base balanceAmar Yahia
The document discusses fluid, electrolyte, and acid-base balance. It describes the composition of body fluid compartments, including total body water, intracellular water, extracellular water, plasma, and interstitial fluid. It discusses third space fluids and the osmolality of body fluids. Electrolytes such as sodium, potassium, calcium, magnesium, and chloride are described along with their general functions. Water imbalance in the form of water loss or excess is covered. Sodium and potassium metabolism and balance is explained in detail, including causes and treatment of deficiencies and excesses.
This document summarizes several clinical trials comparing on-pump coronary artery bypass grafting (CABG) to off-pump CABG. The CORONARY trial found no difference in mortality at 1 year between on and off-pump, but a slightly higher rate of revascularization with off-pump. The ROOBY trial found higher mortality at 5 years with off-pump compared to on-pump. The DOORS trial found better graft patency rates with on-pump (86%) than off-pump (76%). Trials like GOPCABE and SMART found similar outcomes between on and off-pump techniques. The PROMOTE trial found no significant difference in graft patency rates at 3 months between techniques
Acute SMV thrombosis was described in a document that discussed:
1. It remains a life-threatening condition with high mortality despite advances in treatment.
2. It most commonly involves the superior mesenteric vein and is usually secondary to conditions that increase risk of thrombosis.
3. Presentation can be non-specific with abdominal pain but imaging such as CT can clearly identify thrombosis.
1. Liver injuries are commonly caused by blunt or penetrating abdominal trauma. The right lobe of the liver is most frequently injured.
2. Liver injuries are graded from I to VI based on severity. Grade I injuries involve small lacerations while grade VI involve major vascular injuries.
3. Most liver injuries can now be managed non-operatively with techniques like angiography, embolization, and close monitoring. Operative management is reserved for higher grade injuries or those with ongoing bleeding.
This presentation is all about patient prosthetic mismatch.what is PPM?.
Diameters of heart valve
Effective orifice area of different heart valves
How to avoid PPM
How to manage increased gradients across the heart valve
1. The patient presented with right upper quadrant pain 6 months after liver transplantation. Imaging showed a 1 cm pseudoaneurysm arising from the hepatic artery.
2. Due to the tortuosity of the hepatic artery and pseudoaneurysm, endovascular treatment was not possible. The patient underwent surgery to resect the pseudoaneurysm and reconstruct the hepatic artery.
3. At surgery, the pseudoaneurysm was larger than imaging showed, at 2x1.5 cm. It was successfully resected and the hepatic artery was reconstructed with an interrupted suture. The patient had an uneventful recovery.
Management of liver trauma in adults, 2018, by R. LuneviciusRaimundas Lunevicius
1) The document discusses the management of liver trauma in adults, including classifications of liver injuries, principles of management, and case examples.
2) The most important factors in management are the patient's physiology and response to resuscitation, in addition to the anatomical details of the injury seen on CT scan.
3) Most patients with grades I-III injuries can be managed conservatively with observation and follow-up imaging, while grade IV injuries or unstable patients often require surgery.
The document discusses the use of extracorporeal membrane oxygenation (ECMO) as a treatment for acute respiratory distress syndrome (ARDS). It summarizes that ECMO can act as a bridge to allow the lungs to heal, but comes with risks of bleeding and other complications. While some early trials did not find benefit, more recent evidence from the CESAR trial in the UK showed reduced mortality for ARDS patients who received ECMO support at a specialized center, along with protocolized lung-protective ventilation. Further research is still needed to identify patient selection criteria and standardized protocols.
1. Extracorporeal membrane oxygenation (ECMO) and continuous renal replacement therapy (CRRT) are important life support therapies used in intensive care units.
2. ECMO uses an external circuit to oxygenate blood and remove carbon dioxide, functioning as a bridge to recovery, transplant, or decision. CRRT slowly removes waste and fluid from the blood of patients with kidney failure or injury.
3. The document discusses the principles, indications, techniques, and complications of ECMO and CRRT, highlighting their roles in supporting critically ill patients with cardiac, respiratory, or renal issues.
The liver is frequently injured in abdominal trauma due to its location and size. Most liver injuries can be managed non-operatively through observation, though some require procedures to control bleeding. The severity of injury is graded on a scale of I to VI. For blunt trauma patients who are hemodynamically stable without ongoing bleeding, non-operative management is preferred with monitoring and CT scans. Surgical management is used for unstable patients or those with significant bleeding, and focuses on controlling bleeding through sutures, packing, or clamping blood vessels.
The assistant stands on the opposite side of the table from the surgeon.
Incision: A flank incision is made over the 11th rib extending from the midaxillary line to the
costal margin. The 11th rib is not routinely resected.
DEPT OF UROLOGY, KMC AND GRH, CHENNAI 38
The subcutaneous tissue and external oblique muscle are divided in line with the skin incision.
The internal oblique and transversus abdominis muscles are then divided in the same plane.
The retroperitoneal space is entered by incising the transversalis fascia.
The peritoneum is identified and incised longitudinally along the lateral
Early degeneration of a bioprosthetic mitral valve complicated by a large lef...pascal Pascal, Richard
This case report describes a 71-year-old man who presented with symptomatic early degeneration of a bioprosthetic mitral valve replacement complicated by a large left atrial thrombus. Transesophageal echocardiography revealed severe calcification and stenosis of the bioprosthetic valve as well as a thrombus in the left atrium. The patient underwent mechanical mitral valve replacement and left atrial thrombectomy. Calcium supplementation required for the patient's prior parathyroidectomy may have contributed to early bioprosthetic valve deterioration. Despite anticoagulation, the large thrombus formed due to left atrial stasis from mitral stenosis.
1) Liver trauma is the second most common organ injured in blunt abdominal trauma and the most common injured in penetrating trauma, occurring in 1-8% of patients with multiple blunt trauma.
2) The liver is susceptible to injury due to its size, friable parenchyma, thin capsule, and fixed position near the ribs and spine.
3) Liver injuries are classified based on the mechanism of injury, type and degree of damage, localization within liver lobes/segments, and whether associated vessels or bile ducts are damaged. Grades I-II are minor injuries while Grades III-V require surgical intervention and Grade VI is incompatible with survival.
This document summarizes the surgical technique and complications of central venous catheters for hemodialysis. It discusses the basic concepts, pre-operative evaluation including imaging of central veins, catheter insertion technique, and perioperative and long-term care and complications. The best site for catheter placement is the right internal jugular vein to minimize risks of kinking and central vein stenosis. Ultrasound and fluoroscopy guidance are recommended for accurate placement and tunneling of cuffed catheters. Major perioperative risks include pneumothorax, hemothorax, and nerve injury, while long-term complications consist of infection, thrombosis, stenosis, and catheter malfunction.
The liver is the second most commonly injured organ in blunt abdominal trauma and the most commonly injured in penetrating abdominal trauma. Non-operative management of liver injuries is now the standard of care for hemodynamically stable patients and has a success rate of over 85%, even for high-grade injuries. Failure of non-operative management is usually due to other intra-abdominal injuries rather than the liver injury itself. Operative intervention is indicated for hemodynamically unstable patients or those who fail non-operative management.
Bile Duct Injury and Post Cholecystectomy Biliary StrictureArifuzzaman Shehab
Bile duct injuries are a devastating complication of gallbladder surgery that can have tremendous physical and mental effects on both surgeons and patients. Early recognition within 72 hours allows for minimal inflammation and the highest chance of successful repair. Diagnosis involves signs of abdominal pain and jaundice along with imaging and blood tests showing bile leakage and liver dysfunction. Management depends on the severity and location of the injury, ranging from endoscopic stenting to immediate surgical repair.
- Mesenteric venous thrombosis is an uncommon disease that involves thrombosis of the mesenteric veins with risks including obesity, surgery, and inflammatory bowel disease.
- Patients typically present with diffuse abdominal pain, nausea, diarrhea, or gastrointestinal bleeding. Diagnosis involves blood tests, imaging like CT scans showing dilated bowel loops and ascites, and exclusion of other causes.
- Treatment depends on the severity and includes anticoagulation, bowel rest, thrombolysis, endovascular procedures, and potentially bowel resection surgery. With treatment, mortality rates are around 20-30% with 70% 5-year survival. Lifelong anticoagulation is usually recommended.
Severe bleeding can occur from arteries, veins, or capillaries and cause death within minutes if not treated. Direct pressure, elevation, and digital pressure are emergency treatments for severe bleeding. Direct pressure involves pressing a sterile dressing firmly over the wound for 10-15 minutes until bleeding stops. Elevation above the heart slows blood flow and speeds clotting. Digital pressure is applied at pressure points on bones near arteries to control blood flow and must only be used briefly as an addition to direct pressure and elevation.
PREVIEW OF EMT/EMR BLEEDING POWERPOINT TRAINING PRESENTATIONBruce Vincent
Describes the care of the patient with internal and external bleeding. Estimated teaching time 2 hours. Meets or exceeds current US DOT NHTSA 2009 requirements.
The document provides information about shock and external bleeding control. It defines shock as inadequate perfusion of blood to organs. It describes the signs and stages of shock from compensated to decompensated. Treatment for shock includes addressing the cause, placing the casualty flat and raising the legs, loosening clothing, covering with a blanket, establishing IV fluids, and monitoring vitals. The document also discusses types of bleeding, methods for control like direct pressure and tourniquets, and relates blood loss percentages to shock classes. Further, it outlines management of gunshot wounds, impaled objects, and amputated extremities.
This document discusses different types of open wounds such as incisions, lacerations, abrasions, puncture wounds, and penetration wounds. It also discusses different types of dressings used to treat wounds including sterile, bulky, and occlusive dressings. The document outlines the steps to control external bleeding which include applying direct pressure to the wound, elevating the wound above the level of the heart, applying a dressing, and monitoring the patient. It also discusses using pressure points and a tourniquet to control severe bleeding.
This document summarizes the major arteries and veins supplying the head and neck. It begins by listing the common carotid, external carotid, internal carotid, and subclavian arteries. It then describes the origins, branches, and relations of these arteries. It also discusses the major veins that drain the head and neck, including the external jugular, internal jugular, retromandibular and subclavian veins. It provides diagrams to illustrate the anatomy.
This document describes different types of wounds, principles of bleeding, and first aid procedures for external and internal bleeding. It outlines signs and symptoms of blood loss and discusses managing external bleeding through direct pressure, indirect pressure, or tourniquet methods as a last resort. For internal bleeding, signs may be subtle but include pale skin and changing vital signs. First aid involves maintaining ABCs, fluids, blood transfusion, and potentially surgery while seeking medical help.
1) First aid involves providing immediate assistance to an injured or ill person until emergency medical help arrives. It aims to preserve life, prevent worsening of conditions, and promote recovery.
2) When providing first aid, one should protect oneself and the victim, examine the victim to check for breathing, responsiveness, bleeding, and pulse, and alert emergency services.
3) Basic first aid treatments include controlling bleeding, opening the airway, giving CPR if needed, placing in recovery position, and monitoring the victim until help arrives. CPR involves chest compressions and artificial ventilation to keep blood circulating.
This document discusses the approach to evaluating a patient presenting with chest pain in a primary care setting. It emphasizes that the history is the most important factor in diagnosis, not investigations alone. It provides examples of several cases presenting with chest pain and the most likely diagnosis based on factors like the patient's age, medical history, characteristics of the pain, and findings on examination. Common life-threatening causes of chest pain are discussed along with the limitations of some diagnostic tests.
This document discusses different types of wounds, including their classification, characteristics, and management. It describes closed wounds that occur with blunt trauma, like contusions, and open wounds from penetrating trauma, like abrasions, lacerations, incisions, punctures, and gunshot wounds. It outlines dangers of wounds like bleeding and infection. First aid aims to stop bleeding and minimize germ entry. Bleeding can be external or internal, and types include arterial, venous, and capillary. Direct pressure, elevation, pressure points, and tourniquets can control bleeding. Internal bleeding signs include pain and tenderness over injured areas and signs of shock. Management involves controlling external bleeding, positioning, and promptly transporting to the hospital
Chest pain: nursing assessment and managementJamie Ranse
This document discusses the nursing assessment and management of chest pain. It covers causes of chest pain like myocardial infarction, risk factors, the chain of survival process for cardiac events, how to prioritize patients based on their condition, performing a full patient assessment, potential nursing interventions, and medical management options like percutaneous transluminal coronary angioplasty (PTCA) or thrombolytics. The goal is to recognize cardiac issues early, treat patients appropriately, and guide them to the best treatment pathway.
The document discusses emergency triage in a hospital emergency department. It describes triage as a process where a nurse rapidly evaluates patients upon arrival to determine the level of acuity and priority for care. The triage nurse assesses factors like chief complaint, appearance, vital signs, history and assigns the patient to one of five standardized triage levels, from level 1 being life-threatening to level 5 being non-urgent, with corresponding timeframes for clinician assessment. The primary role of the triage nurse is to make decisions about priority of care while monitoring for communicable diseases or violence.
TRIAGE, que significa clasificar...
he aqui una presentacion hecha por mi sobre la clasificacion de pacientes (:
recordemos que el objetivo del triage es salvar la mayor cantidad de vidas posibles.. no de salvar al que esta más herido.. u.u
Pm. Diana Estefany Castro Gómez
The document discusses a mobile app called iTriage that helps patients find the best treatment options for their medical issues. It was created by two ER physicians to help patients navigate the healthcare system by connecting their symptoms to the appropriate provider based on their insurance plan and level of care needed. The app aims to save health plans money by directing patients to lower-cost providers like urgent care centers instead of emergency rooms for non-emergency issues. It provides treatment options and helps patients find in-network doctors and facilities on their mobile devices.
1. Chest pain is a common complaint that can be caused by cardiac, respiratory, gastrointestinal, vascular, musculoskeletal and other issues. A thorough history and physical exam is needed to determine the underlying cause.
2. A careful differential diagnosis should be established to identify life-threatening issues like acute coronary syndrome, pulmonary embolism, or aortic dissection versus more benign conditions.
3. Appropriate tests and investigations should then be ordered based on the leading clinical diagnosis to identify the cause of chest pain and guide management.
This document discusses differentiating between cardiac and non-cardiac causes of chest pain. Cardiac causes include ischemic issues like myocardial infarction and non-ischemic problems like pericarditis. Non-cardiac causes range from gastrointestinal issues, pulmonary problems, musculoskeletal pain and even shingles. It is important to thoroughly assess patients experiencing chest pain to determine location, quality and accompanying symptoms to correctly identify potential life-threatening issues and provide appropriate intervention.
Triage is the process of sorting patients based on the urgency of their condition to provide the right care to the right patient at the right time. It involves initially assessing patients at arrival to identify those needing immediate care, determine the appropriate treatment area, and avoid congestion. The goals are to treat the most severely injured first while maximizing survival in a mass casualty event. Triage categories range from resuscitation to non-urgent to ensure critical patients receive rapid medical attention. Reassessment is important as a patient's condition may deteriorate while waiting.
Kristopher Maday, MS, PA-C is the Program Director and Associate Professor at the University of Tennessee Health Science Center Physician Assistant Program. He provided a summary of several risk scores used to risk stratify patients presenting with chest pain including the PURSUIT, TIMI, GRACE, FRISC, HEART, and EDACS scores. Several of these scores such as GRACE and TIMI were developed and validated in large international randomized controlled trials to predict short and long term risks of death and myocardial infarction. The FRISC trial examined the benefit of early revascularization in unstable coronary syndrome patients. The EDACS score was derived and validated in two hospital studies to predict low risk in an accelerated
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Osvaldo Bernardo Muchanga
Gastrointestinal Infections
GASTROINTESTINAL INFECTIONS result from the ingestion of pathogens that cause infections at the level of this tract, generally being transmitted by food, water and hands contaminated by microorganisms such as E. coli, Salmonella, Shigella, Vibrio cholerae, Campylobacter, Staphylococcus, Rotavirus among others that are generally contained in feces, thus configuring a FECAL-ORAL type of transmission.
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2. Arterial bleeding during EUS-guided pseudocyst
drainage stopped by placement of a covered self-
expandable metal stent
Adrian Săftoiu1,2
Email: adriansaftoiu@aim.com
Lidia Ciobanu3
Email: ciobanulidia@yahoo.com
Andrada Seicean3*
*
Corresponding author
Email: andradaseicean@yahoo.com
Marcel Tantău3
Email: matantau@gmail.com
1
Research Center of Gastroenterology and Hepatology Craiova, University of
Medicine and Pharmacy Craiova, Romania, Copenhagen, Denmark
2
Gastrointestinal Unit, Faculty of Health and Medical Sciences, Copenhagen
University, Copenhagen, Denmark
3
Regional Institute of Gastroenterology and Hepatology University of Medicine
and Pharmacy Cluj-Napoca, Romania, str. Croitorilor nr 19-21, Cluj-Napoca
400192, Romania
Abstract
Background
Hemorrhagic complications during EUS-guided pseudocyst drainage can occur, because the
vessels on the internal wall of the pseudocyst might be compressed by the fluid and thus not
visible on color Doppler or even power Doppler EUS.
Case presentation
We report a case of an immediate internal spurting arterial bleeding precipitated during EUS-
guided pseudocyst drainage which stopped instantaneously by placement of a double flanged
covered self-expandable metal stent through mechanical hemostasis.
Conclusion
In an unusual situation of bleeding from collateral circulation near the pseudocyst wall during
pseudocyst drainage, the placement of an expandable metal stent proved to be useful.
3. Keywords
Endoscopic ultrasound, Pancreatic pseudocyst, Upper gastrointestinal bleeding, Portal
hypertension
Background
Endoscopic ultrasound (EUS)-guided pseudocyst drainage is nowadays a routine procedure
performed in tertiary centers, with minimal morbidity and mortality. Initial procedures based
on one-step EUS-guidance were developed almost 15 years ago and they still represent the
standard of care in most advanced GI units [1,2]. During the years, EUS-guided procedures
for gastric or duodenal transmural drainage of pancreatic pseudocysts benefitted from a
certain number of technical improvements, although the technique still has a long learning
curve [3,4]. Despite the increased safety of transmural puncture based on the avoidance of
major vessels with increased use of EUS Doppler techniques, there are still immediate
complications consisting mainly of perforations and bleeding in about 1-2% of cases [5,6].
Nevertheless, if there is a careful selection of the patients, the EUS-guided drainage
procedure is considered safer as compared with surgical cyst-gastrostomy [7]. The case report
describes an immediate spurting arterial bleeding precipitated during EUS-guided pseudocyst
drainage which stopped instantaneously by placement of a double flanged covered self-
expandable metal stent.
Case presentation
We present the case of a 41 years old male with a long standing history of ethanol
consumption. His past medical history was significant for pancreatic disorders: he had two
episodes of acute pancreatitis induced by ethanol consumption. Four weeks before the
drainage procedure, he presented in the emergency department presenting with intense upper
abdominal pain, nausea and vomiting, induced again by heavy ethanol consumption.
Biological markers revealed elevated levels of blood and urine amylases (466 IU/L and 2397
IU/L) and leucocytosis. An emergency transabdominal ultrasound identified a large
pseudocyst located near the pancreatic tail, confirmed by the contrast-enhanced CT scan. No
other fluid collection or necrotic areas were revealed. Nevertheles, the CT scan indicated the
presence of the splenic vein thrombosis and the collaterals near the pancreatics tail region, as
well as in the gastric wall.
As the initial therapeutic option, we took into account the possibility of a transcutaneous
ultrasound-guided approach or an endoscopic approach by placing a stent using EUS-
guidance from the stomach. As an important collateral circulation developed as a
consequence of splenic vein thrombosis, after the inform consent was signed, our choice was
endoscopic stenting using an EUS-guided procedure with avoidance of major vessels through
the use of Doppler techniques. We used a therapeutic EUS scope with a large 3.8 mm channel
(Olympus GIF-UCT 140, Olympus, Tokyo, Japan) coupled with the corresponding
ultrasound system (Aloka Alpha10, Aloka, Tokyo, Japan). The pseudocyst was visualised
from the smaller gastric curvature and an area thought to be devoid of major vessels was
carefully selected by the use of color and power Doppler. Under EUS-guidance the
pseudocyst was punctured using the special device with a trocar and cutting blade (Navix,
Xlumena, Mountain View, California, USA). During the passage of the cutting blade through
4. the gastric wall a significant spurting (pulsatile) arterial bleeding started from the puncture
level inside the pseudocyst, being easily visible on the gray-scale mode (Figure 1, Additional
file 1: Movie S1), with minimal intragastric bleeding. A 0.035″ hydrophilic guidewire (Cook,
Limerick, Ireland) was placed through the 19 G trocar and coiled deeply inside the
pseudocyst. The procedure has been continued with both EUS-guidance, but also intermittent
radiological check-ups of the guidewire position inside the pseudocyst.
Figure 1 Significant spurting (pulsatile) arterial bleeding originating from the puncture
level inside the pseudocyst.
A special double flanged covered expandable stent of 10 mm in the saddle length (between
the two flanges) and 10 mm in diameter when expanded (Axios, Xlumena, Mountain View,
California, USA) was then uploaded on the guidwire. The stent is collapsed into a 10.8 Fr
delivery catheter system which adapts into the therapeutic channel of an EUS scope and then
expands separately for the distal and proximal flanges, without the ability of being collapsed
into the delivery catheter. The stent was then deployed from the distal part under EUS and
radiological guidance (Figure 2A-B), followed by deployment of the proximal part under
direct endoscopic guidance, using special manufacturers instructions and the steps provided
on the delivery system handle. As a consequence of stent deployment and pressure elicited on
the gastric and pseudocyst wall at the level of the fistula created during the EUS procedure,
the bleeding stopped instantaneously. The patient was then treated with a proton pump
inhibitor and large spectrum antibiotics (cefuroxime and metronidazol) for five days, with
fever of up to 38.3 degrees C, which decreased to normal after 24 hours.
Figure 2 Deployment of the stent under EUS and endoscopic guidance. A. Deployment of
the distal part of the stent under combined EUS and radiological guidance. B. Deployment of
the proximal part of the stent under direct endoscopic guidance.
After 4 weeks with ethanol abstinence, the patient returned for another episode of pain in the
upper abdomen and fever, associated with leucocytosis, but normal amylasemia. Although,
there were no collections visualised on ultrasound or contrast-enhanced CT scan, a decision
to remove the stent endoscopically was taken. The stent was easily snare and taken out, with
minimal bleding of the gastric wall which stopped after adrenaline injections (1 : 10 000) and
argon plasma coagulation. The pain immediately and the patient was discharged. There were
no episodes of bleeding or recurrent acute pancreatitis during a 6 months follow-up, and the
pseudocyst did not recurred.
Discussions
Bleeding during drainage of pancreatic pseudocysts is a severecomplication as it might occur
immediately [8] or delayed [9], leading to increased morbidity and even mortality. These are
due to prolongation of the period and an increased transfusion rate, as well as because of the
necessity of emergency surgical intervention. Moreover, the subgroup of patients with
complications after the drainage of pancreatic pseudocysts are the most prone to an increased
mortality. Hence, transcutaneous or endoscopic drainage of pancreatic pseudocysts were
replaced by EUS-guided drainage procedures which decrease significantly the risk of
bleeding [10]. Nevertheless, even with the use of real-time guidance during EUS, there are
still hemorrhagic complications in less than 1-2% of cases, because the vessels on the internal
wall of the pseudocyst might be compressed by the fluid and thus not visible on color
Doppler or even power Doppler EUS. In our case, the sudden spurting arterial bleeding was
5. most probably casused by the blade which extends in the tip of the 19G trocar, probably by
damaging concealed vessels at the internal wall of the pseudocyst, which were not visible
initially, but were probably decompressed during EUS-guided drainage, through initial
aspiration of the fluid, but also during exchange of the EUS accesories which probably lead
to leakage of the pseudocyst fluid.
Although single or multiple plastic stents, as well as nasocystic drainage catheters are used
for EUS-guided pseudocyst drainage, expandable stents were also considered as viable
alternatives as they keep open the tract created between the stomach and pseudoscyst cavity.
This is beneficial especially for the cases with large, infected pseudocysts or pancreatic
abscesses. Several articles already described the use of covered expandable metal stents for
the drainage of pancreatic pseudocysts, having the advantage of a large diameter with a
possible decrease in the reccurence rate [11]. There are however disadvantages which includ
stent migration and difficulty of insertion for large stents [12]. Even surgical approaches were
described, with the use of staplers applied transorally by minimal invasive NOTES
procedures, after an initial EUS-guided approach [13]. For our patient we chose a novel
metalic stent with double flanges, which have the intended advantage of preventing
migration, but also induce apposition of the pseudocyst wall and gastric/duodenal wall,
through the covered part, thus preventing leakage and decreasing the perforation risk [14,15].
However, due to the large diameter (10.8 Fr) of the delivery system, the insertion through the
gastric and pseudocyst wall might be difficult if a previous dilation of the initial tract is not
performed using baloon dilators and/or cautery devices (needle knife sphincterotome, hot
needle wires or cystotomes). Even under real-time EUS-guidance with use of color Doppler
techniques, the initial dilation of the tract before stent insertion can possibly cause significant
bleding at the level of the digestive tract wall or pancreatic pseudocyst wall collaterals which
might be compressed by the fluid inside the pseudocyst. Nevertheless, the advantage of a
covered expandable stent is exactly the possibility of stopping the bleeding through
mechanical hemostasis and this has been clearly demonstrated in our case report.
The use of metallic stents in order to control severe bleedings in the GI tract has been already
described in several articles. Thus, a review of preliminary reports suggested that self-
expandable covered metal stents might be considered useful and very effective to control
refractory acute variceal bleeding, being an alternative to the temporary control obtained by
Sengstaken-Blakemore baloon [16]. The stents used have a modified design (with atraumatic
edges and retrieval loops with gold markers at both stent ends) which allows them to be
extracted with a special system after a few days [17]. Covered self-expandable metallic
stenting was also described to be useful in post-sphincterotomy bleeding [18,19] or other GI
malignant tumors diffuse bleeding [20] or in case of the conventional endoscopic fluid
collection drainage [21], which does not stop after usual endoscopic treatment (injection,
coagulation, clipping, etc.). Our case presentation proved that the same approach is useful in
pseudocyst bleeding that occurs during EUS-guided drainage.
Conclusions
This case report shows a rare case of bleeding during the EUS drainage procedure of
pancreatic pseudocyst at the level of the pseudocyst wall. The double flanged covered self-
expandable metal stent proved its utility in such unusual cases with high risk for bleeding due
to colateral circulation.
6. Written informed consent was obtained from the patient for publication of this Case report
and any accompanying images. A copy of the written consent is available for review by the
Editor of this journal.
Abbreviations
EUS, Endoscopic ultrasound; CT scan, Computed tomography
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
ASaftoiu did the EUS-guided pseudocyst drainage, LC, ASeicean and MT selected the
patient for the drainage and followed him up. All authors have been involved in drafting the
manuscript or revising it and have given final approval of the version to be published.
Acknowledgement
We are indebted to the medical staff which took part actively in the live demo, and especially
to Mr. Tom de Simio, Xlumena, Mountain View, California, USA. Devices used in the
procedure were kindly provided by Xlumena, both the Navix device and the Axios double
flanged stent.
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Additional file
Additional_file_1 as AVI
Additional file 1: Movie S1. Significant spurting (pulsatile) arterial bleeding originating
from the puncture level inside the pseudocyst.