Ok all, need your help with a difficult case!

[traumadoc1985]

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Ok here goes. so I have this new patient that was sent to me by their pcp. This guy is 29, He is obese, has hep c from a blood transfusion he recieved as a child, he has portal htn, dm type 1, he has past surgical history of appy, choley w/ liver biopsy, and nissen fundoplication. Now he has been complaining of constant vomiting, abd and chest pain, and having GI bleeds. So I ordered upper gi studies which came back showing the nissen had came apart and his hiatal hernia is back. Now I have some issues with this one, he is pretty unhealthy, but I would like to help him. Now do I operate and take down the nissen or reoperate and fix it? Any opinions and help would be appreciated. I told him it would probabley be a pretty big operation.🙂

 

[celling]

Ok here goes. so I have this new patient that was sent to me by their pcp. This guy is 29, He is obese, has hep c from a blood transfusion he recieved as a child, he has portal htn, dm type 1, he has past surgical history of appy, choley w/ liver biopsy, and nissen fundoplication. Now he has been complaining of constant vomiting, abd and chest pain, and having GI bleeds. So I ordered upper gi studies which came back showing the nissen had came apart and his hiatal hernia is back. Now I have some issues with this one, he is pretty unhealthy, but I would like to help him. Now do I operate and take down the nissen or reoperate and fix it? Any opinions and help would be appreciated. I told him it would probabley be a pretty big operation.🙂

What's his MELD score? Does he have much ascites? How coagulopathic is he?

If the portal HTN is pretty bad, the GI bleeds may be from portal gastropathy or varices. Has he had a recent EGD?

 

[doc05]

Sounds like he needs a reoperation and not by you. refer to someone who does a lot of this work -- very few surgeons have much experience with this, and there's no sense in creating a new complication.

 

[blue2000]

I agree with doc05. Depending on his liver function, he may be a good candidate for a gastric bypass, but it would be high risk. Where is his GI bleed coming from? Cameron's lesions from hiatal hernia, varices? That might help me make my decision. I personally wouldn't operate on him; I don't have the hospital resources to support a high risk patient through a major recovery (for instance, our platelets come from the university hospital blood bank 2 hours away.) Is his hernia causing him to be obstructed? Does he have esophageal motility disorder? I would need a lot more information before I could make a plan.

 

[SLUser11]

Where is his GI bleed coming from? Cameron's lesions from hiatal hernia, varices?

Hemobilia for sure. I'm going full zebra with this one. He had a liver biopsy, after all.....



Also, I didn't read anything about an EGD in the OP...

 

[tussy]

I would get GI medicine involved and try to manage his symptoms medically if at all possible. Surgery on as last resort, and probably want someone with lots of experience doing it. Also, needs a scope if it hasn't been done.

 

[cpants]

MELD score is critical on this one. Mortality can range from close to normal to close to certain death from any surgery based on the MELD.

 

[Docgeorge]

Ok here goes. so I have this new patient that was sent to me by their pcp. This guy is 29, He is obese, has hep c from a blood transfusion he recieved as a child, he has portal htn, dm type 1, he has past surgical history of appy, choley w/ liver biopsy, and nissen fundoplication. Now he has been complaining of constant vomiting, abd and chest pain, and having GI bleeds. So I ordered upper gi studies which came back showing the nissen had came apart and his hiatal hernia is back. Now I have some issues with this one, he is pretty unhealthy, but I would like to help him. Now do I operate and take down the nissen or reoperate and fix it? Any opinions and help would be appreciated. I told him it would probabley be a pretty big operation.🙂

Sometimes discretion is the better part of valor. I would not touch this guy unless you had no choice.