(吃前晚便当做早餐).ppt

Case Discussion:Acute Mesenteric Ischemia Ri 柯雅琳 2008/02/18 Past history 61 y/o man Past medical history: DCM, LVEF 22%, 4-chamber dilatation Afib DM noted for 3 years CAD s/p PTCA PAOD s/p sequestrectomy STSG Personal habits: Alcohol: 2 glasses of 高粱 per day Smoking: 0.5PPD for 40 yrs, quitted for 7-8 yr Chief complaint 2008/01/18:Sudden onset left arm pain OPD: left brachial artery thromboembolism 2008/01/18 20:30 Emergent embolectomy of the left brachial artery Post-OP Course 2008/01/19 09:30Acute onset epigastralgia PESoft, no rebounding painBS: Hyperactive, no metallic sound Hx of eating contaminated food?(吃前晚便當做早餐) Post-OP Course 2008/01/19 10:53 Nausea(+), vomiting x 1( food content) PE:Soft, BS: normoactive, tympanicrebounding pain(-), McBourney point tenderness(-), psoas sign(-) LabCK 54 CK-MB 19 Post-OP Course 2008/01/19 12:20: Emergent abdominal CT SMA occlusion Endovascular Embolectomy: 2008/01/19 13:30-19:50 RFA route SMA occlusion, 5cm from origin, about 5cm in length. Poor distal flow Severe stenosis, unable to pass the guide wire Thrombosuction: also failed Explained to the familyArrange laparotomy 2nd Laparatomy 2008/01/21 08:00 Tube-duodenostomy Tube-ileostomy R/D in douglas pouch, area below T-colon near Treitz ligment Discussion Surgical Intervention of Acute Mesenteric Ischemia Acute Mesenteric Ischemia A Clinical Review Arch Intern Med.?2004;164:1054-1062. Standard embolectomy via a transverse arteriotomy in the proximal SMA Resection of clearly nonviable bowel The ends of the bowel may be brought out as stomas Thompson JS. Edgar J. Poth Memorial Lecture. Surgical aspects of the short-bowel syndrome. [Review] [40 refs] [Journal Article. Review] American Journal of Surgery. 170(6):532-6, 1995 Dec. * * 2 x 1 cm 3 x 1 cm Post-op radial pulsation (+); warmth of the left hand (+) Segmental mucosal necrosis of the small intestine 5cm dark red embolism at 5 cm distal to the origin of SMA Tube-duodenostomy Tube-i