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04-24-2008, 08:41 AM
1) Haemorrhage from anastomotic line
m Diagnosis: Ryle tube gives bloody discharge.
mTreatment:
Morphia Blood transfusion
Ice cold lavage through Ryle's tube.
If bleeding persit after 24 hours blood transfusion re-operation.


2) Paralytic Ileus
m Diagnosis and treatment: see later


3) Stomal obstruction (Vomiting)
m Aetiology:
A) Oedema of the anastomotic line so suction should be continued for 3 days and anastomotic line should be wide enough.
B) Occurrence of retrograde jejunogastric intussusception. barium meal may reduce it within short time otherwise re-exploration should be done. The loop is extracted and fixed to prevent recurrence.
C) Hypertrophied antral mucosa may obstruct the duodenum after Billorith I operation by ball valve obstruction . Excision of the redundant mucosa prevent its occurrence.
D) Technical factors e.g. twisting of the jejunum during anastomosis.
E) Apparent obstruction due to atonic stomach but endoscopy can exclude this cause.


m Treatment:
Drip and suction should be continued for long time. If conservative measures failed operation may be needed.


4) Duodenal blow out
m Aetiology
Due to operation on hot duodenum ( during ulcer activity ) or stump ischemia. If the blow out occurs while the drain is still present, (usually in the 4th day), the condition will end in duodenal fistula. But if the condition occurred after removal of the drain diffuse peritonitis may occur.
m Treatment
Nothing by mouth and total parentral nutrition. If there is no distal obstruction the fistula will be closed spontaneously but may take long time. If not closed by conservative measures surgery may be needed.


5) Acute postoperative pancreatitis
The condition carries a high mortality and the treatment is along the usual lines.


6) Recurrent Ulcer, "anastomotic ulcer"
m Aetiology: Persistent hyperacidity due to: Incomplete operation
Zollinger. Ellison syndrom.
m Pathology: Site: 1- on the gastric side of the stoma.
2- or the efferent loop of the jejunum.
Does not involve the afferent loop due to neutralization of acidity by alkalinity of bile.
m Cl. picture:
Recurrence of original picture of ulcer but the periodicity is lost, pain is severe and haematemesis usually occurs.
m Investigations:
1- Barium meal:
Tender point over the ulcer under the screen.
Speck of barium after evacuation i.e. ulcer nich.
2- Gastroscope: The ulcer can be detected.
m Treatment: Medical treatment usually fails.
Vagotomy not done do vagotomy.
Incomplete vagotomy do trunkal vagotomy.
Partial gastrectomy subtotal gastrectomy.


7) Gastrojejunocolic Fistula
m Due to: deep penetrating anastomotic ulcer open into the colon.
m Cl. picture: Watery diarrhea due to irritation of the colon by gastric acidity, foul eructation and rarely true fecal vomiting.
m Diagnosis: Barium meal or enema detect the fistula.
m Treatment: Resection of the mass containing the fistula with vagotomy and subtotal gastrectomy.


8) Postgastrectomy syndromes
A) Nutritional syndromes:
Steatorrhea, Diarrhea, Gross malabsorption states, vitamin B deficiency, Calcium deficiency and Anemia.
1. Megaloplastic anemia :due to deficiency of intrinsic factor causing failure of absorption of vit B12.
2. Iron deficiency anemia: due to removal of the first part of the duodenum.
Both types are treated by Vit B12 and Iron injections.

B) Postcibal syndromes: (Dumping Syndromes):
1- Early dumping "30 minutes" due to rapid evacuation of the stomach ­ osmotic pr. in the intestine Extraction of fluid from blood to intenstine hypovolaemia Fainting, Tachycardia, Sweating.
2- Late dumping "1.2 hours" due to rapid evacuation of high glucose diet rapid hyperglycaemia overstimulation of insulin sec. hypoglycaemia fainting, tachycardia Sweating.
Treatment: Semi-solid food with low glucose content. can avoid both.
3- Bilious Vomiting: Due to valvular obstruction of the afferent loop when the stomach is filled with food. This makes food pass into intestine without bile and bile is evacuated into empty stomach causing irritation and vomited without food. It can be prevented by avoiding long afferent loop and treated by jejunojejunostomy.
SOURCE: DR. AYMAN SALEM'S BOOK
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