1/43. Expanding septum pellucidum cyst due to a traumatic ventriculoperitoneal shunt.A rare complication of a ventriculoperitoneal (VP) shunt is reported. Serial imaging studies demonstrated the formation of an expanding septum pellucidum cyst after an indwelling shunt tube penetrated the wall of the septum pellucidum. This complication should be borne in mind if patients have symptoms of intermittent obstructive hydrocephalus or related to pressure effects from the septum pellucidum after VP shunting.- - - - - - - - - - ranking = 1keywords = pressure (Clic here for more details about this article) |
2/43. Acute gastric dilatation revisited.First described by S.E. Duplay in 1833, acute gastric dilatation has since been well documented in the literature. Several theories of the pathogenesis of acute gastric dilatation have been postulated. In 1842, Karl Freiherr von Rokitansky described the superior mesenteric artery syndrome, followed by W. Brinton in 1859 with the atonic theory. C.R. Morris et al. introduced debilitation and anesthesia as predisposing factors. Although rare, gastric necrosis is the most severe consequence of acute gastric dilatation. Vascular insufficiency secondary to increased intragastric pressure is the critical factor. We report an unusual case of acute gastric dilatation with subsequent necrosis of uncertain etiology.- - - - - - - - - - ranking = 1keywords = pressure (Clic here for more details about this article) |
3/43. Esophageal intramural pseudodiverticulosis associated with esophageal perforation.We report a rare case of esophageal intramural pseudodiverticulosis with lower esophageal stricture which perforated into the peritoneal cavity after the patient vomited. A 61-year-old man was admitted with severe chest and epigastric pain after dysphagia and vomiting. Under a diagnosis of upper gastrointestinal perforation, laparotomy was performed. The anterior wall of the abdominal esophagus was found to have ruptured, and proximal gastrectomy with abdominal esophagectomy was performed. Histological examination revealed esophageal intramural pseudodiverticulosis with esophageal stricture distal to the site of rupture, and postoperative endoscopy showed diffuse pseudodiverticulosis in the remaining esophagus. The patient is free of symptoms 5 years after the surgery. This case suggests that careful treatment may be indicated in patients with esophageal intramural pseudodiverticulosis with stricture and elevated intraluminal pressure, to minimize the possibility of severe complications such as esophageal perforation.- - - - - - - - - - ranking = 1keywords = pressure (Clic here for more details about this article) |
4/43. Manometric heterogeneity in patients with idiopathic achalasia.BACKGROUND & AIMS: In certain cases of achalasia, particularly those in early stages with minimal endoscopic or radiographic abnormalities, the diagnosis may rely on manometry, which is the most sensitive test for the disease. The aim of this study was to critically evaluate the manometric criteria in a population of patients with idiopathic achalasia. methods: Clinical histories and manometric recordings of 58 patients with idiopathic achalasia and 43 control subjects were analyzed with regard to esophageal body contraction amplitude, peristaltic effectiveness in terms of both completeness and propagation velocity, lower esophageal sphincter (LES) resting pressure, LES relaxation pressure, and intraesophageal-intragastric pressure gradient. Variants of achalasia were defined by finding manometric features that significantly differed from the remainder of achalasia patients, such that the diagnosis might be questioned. RESULTS: Four manometrically distinct variants were identified. These variants were characterized by (1) the presence of high amplitude esophageal body contractions, (2) a short segment of esophageal body aperistalsis, (3) retained complete deglutitive LES relaxation, and (4) intact transient LES relaxation. In each instance, the most extreme variant is discussed and compared with the remainder of the achalasia population and with controls. CONCLUSIONS: The significance in defining these variants of achalasia lies in the recognition that these sometimes confusing manometric findings are consistent with achalasia when combined with additional clinical data supportive of the diagnosis. Furthermore, such variants provide important clues into the pathophysiology of this rare disorder.- - - - - - - - - - ranking = 3keywords = pressure (Clic here for more details about this article) |
5/43. Abdominal compartment syndrome.Abdominal compartment syndrome may be defined as the deleterious pathophysiologic consequences of a significant increase in intra-abdominal pressure. These alterations can affect respiratory mechanics, cardiovascular system, regional blood flow, renal function, urine output, and intracranial pressure. Although the syndrome may be associated with many clinical situations, the most common are severe abdominal trauma and ruptured abdominal aortic aneurysm. Diagnosis depends upon recognition of the clinical syndrome followed by an objective measurement of intra-abdominal pressure, the most common being the measurement of bladder pressure. Treatment consists of adequate fluid resuscitation and surgical decompression when necessary.- - - - - - - - - - ranking = 4keywords = pressure (Clic here for more details about this article) |
6/43. Boerhaave's syndrome: a pediatric case.BACKGROUND: The term Boerhaave's syndrome refers to esophageal rupture after a sudden increase in intraluminal pressure. This syndrome is most common among alcoholic adult men. This case report is that of a pediatric patient with a similar pathologic process. STUDY: A 6-month-old Hispanic boy with acute lymphoblastic leukemia on chemotherapy arrested 3 weeks into his induction therapy. Diagnostic and therapeutic procedures revealed a hydropneumothorax, which was managed with chest tube drainage. The underlying etiology was revealed 10 days later when feeds were introduced and found exiting the chest tube. A contrast study confirmed esophageal perforation, which was surgically repaired. CONCLUSION: A nontraumatic hydropneumothorax should raise the possibility of Boerhaave's syndrome (spontaneous esophageal rupture), even in pediatric patients. Such a finding warrants a contrast study to facilitate early diagnosis.- - - - - - - - - - ranking = 1keywords = pressure (Clic here for more details about this article) |
7/43. rupture of the round window membrane.A perilymph leak into the middle ear through a ruptured round window membrane results in the symptoms of hearing loss, tinnitus and vertigo, either singly or in combination. The case histories of thirteen patients with such a fistula are described, these patients having in common a predisposing incident which had led to a rise of C.S.F. pressure. Symptomatology and the results of investigation are analysed and operative technique and results discussed. While it appears that vertigo uniformly responds very satisfactorily to operative treatment the improvement in hearing loss and tinnitus is more difficult to predict.- - - - - - - - - - ranking = 1keywords = pressure (Clic here for more details about this article) |
8/43. Cardioactive steroid poisoning from an herbal cleansing preparation.We describe a case of unintentional poisoning from a cardioactive steroid and the subsequent analytic investigation. A 36-year-old woman with no past medical history and taking no conventional medications ingested an herbal preparation marketed for "internal cleansing." Its ingredients were neither known to the patient nor listed on the accompanying literature. The next morning, nausea, vomiting, and weakness developed. In the emergency department, her blood pressure was 110/60 mm Hg, and her pulse rate was 30 beats/min. Her ECG revealed a junctional rhythm at a rate of 30 beats/min and a digitalis effect on the ST segments. After empiric therapy with 10 vials of digoxin-specific Fab (Digibind), her symptoms resolved, and she reverted to a sinus rhythm at a rate of 68 beats/min. Her serum digoxin concentration measured by means of the fluorescence polarization immunoassay (Abbott TDx) was 1.7 ng/mL. Further serum analysis with the Tina Quant digoxin assay, a more digoxin-specific immunoassay, found a concentration of 0.34 ng/mL, and an enzyme immunoassay for digitoxin revealed a concentration of 20 ng/mL (therapeutic range 10 to 30 ng/mL). serum analysis by means of high-performance liquid chromatography revealed the presence of active digitoxin metabolites; the parent compound was not present. When the diagnosis of cardioactive steroid poisoning is suspected clinically, laboratory analysis can confirm the presence of cardioactive steroids by using immunoassays of varying specificity. An empiric dose of 10 vials of digoxin-specific Fab might be beneficial in patients poisoned with an unknown cardioactive steroid.- - - - - - - - - - ranking = 1keywords = pressure (Clic here for more details about this article) |
9/43. Ready to go.The patient with a decreased level of consciousness in the absence of trauma presents difficult assessment and intervention problems. This is compounded when the history is vague or nonspecific. In this case, the patient's history of embolic CVA alerted providers to the possibility of another thrombus. This patient's sudden symptoms could have resulted from a clot in the brain, heart or aorta. This patient presented with an altered level of consciousness, vomiting and low blood pressure. As is typical in elderly female patients, she had an unusual presentation of an MI. A myocardial infaction is classified as either transmural or subendocardial. A transmural infarct extends through the full thickness of the myocardium and holds greater-risk of complications due to loss of functional muscle. In a subendocardial infarct, necrosis is limited to the endocardial surface. Although many elderly patients present with subendocardial MIs, this one had a large transmural MI. In general, the circumflex artery serves the lateral and posterior walls of the myocardium, and the right coronary artery (RCA) serves the inferior wall. In an anterior MI, the left anterior descending artery (LAD) is obstructed. This vessel serves the left ventricle, parts, of the septum and paillary muscles. The LAD is often referred to as the "widowmaker" because left ventricular infarcts have a high incidence of mortality. Occlusion of LAD can cause the usual damage of an MI, and can also cause fatal damage to the valves. This patient was in profound cardiogenic shock -- the left ventricle had infarcted and was unable to maintain cardiac output. Because of her recent stroke, she was not a candidate for thrombolytic medication. With ultrasonography, a large area of the anterior wall was found to be akinetic, or not functioning at all. In this care, the sourrounding myocardium not only has to pump blood with less muscle but also to "drag" the dead tissue. This results in a progressively higher rate of O2 cnsumption within the heart, further damage to the strained heart, and death. As cigarette smoking and obesity complete for the leading preventable cause of death in the united states, familiarity with cardiac anatomy and physiology 12-lead interpretation, pharmacology and electrical therapy is essential for all emergency providers- - - - - - - - - - ranking = 1keywords = pressure (Clic here for more details about this article) |
10/43. Rapid neurological deterioration associated with minor head trauma in chronic hydrocephalus.CASE REPORT: An 8-year-old developmentally normal boy (status: post third ventriculostomy and resection of posterior fossa low-grade glioma 4 years earlier and with known history of ventriculomegaly/arrested hydrocephalus) presented to the emergency room with vomiting and lethargy after a minor head trauma. Computed tomography scan of the head revealed no acute changes since previous studies. However, the patient's neurological status rapidly declined in the emergency room, where an emergency ventriculostomy demonstrated increased intracranial pressure. The patient's clinical condition improved over 24 h: he underwent placement of a ventriculoperitoneal shunt without complications and was discharged intact. DISCUSSION: The pathogenesis of rapid neurological decline associated with minor head trauma in chronic hydrocephalus is reviewed.- - - - - - - - - - ranking = 1keywords = pressure (Clic here for more details about this article) |
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