Very curious consult

Discussion in 'Surgery and Surgical Subspecialties' started by roja, Jun 21, 2008.

  1. roja

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    So, on my last week in NYC, I got some really horribly sick patients. This one was signed out to me.

    This one netted the oddest consult request from the ICU.

    71 yo female came in (walking/talking) with a ? hx of melena. (? because of language barrier). Different resident went to see the patient and sure enough, melena, brbpr and the patient proceeded to start having a little bit of brb from her mouth. NGT pulls out 2 liters of brp. To make a long story short, she is intubated and gi scopes her seeing varices but can't isolate the source. She's on all the standard stuff, including pressors and is semi stabilized and signed out. (4 units prbc at this time).

    about an hour later, BRB starts pouring out the mouth. We put in a blakemore tube (getting out another 5 more liters of blood in less than 5 minutes). The bleeding seems to stop. she is now about 10 units in, 10 liters in, ffp, platelets etc. Labile bp, tachy.

    ICU wants a surgical consult and an IR consult. (No way is she going to the IR suite).

    Now, I can't figure out what they wanted the surgeons to do. partial gastrectomy? She had varices.

    Am I missing something?
     
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  3. Varices where? Esophagus? Stomach? Any active bleeders? Ulcers?

    So she received 10 units PRBCs within the first couple of hours? Yeah, that's an automatic indication to take the patient to the OR - usually greater than 5 units of blood in the first 24 hours earns the patient an operation.

    As for what the management for uncontrolled UGIB is? Besides aggressive resuscitation, in the OR they'd likely repeat the EGD...and if they couldn't stop the bleeding (e.g. from an actively bleeding ulcer), options include vagotomy, partial gastrectomy, Billroth I/II, Roux-en-Y, even drainage.
     
  4. dpmd

    dpmd Relaxing
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    At my institution a surgery consult is required for any GI bleeder. This sucks for the intern, and we usually end up doing nothing but advise the team to perform the correct medical treatment that hopefully they would have done anyway (although I think there have been times where this didn't occur and hence the all GI bleeders get a surgery consult rule). There are some surgical interventions that can be performed for esophageal varices (we actually do a fair number of shunts since we see cirrhotics who are still drinking more than we see those who are transplant candidates, not during the "oh **** are they going to die" stage though)
     
  5. Ah, dpmd, thanks for reminding me. Totally forgot to include possible operative management for varices: balloon tamponade, TIPS, portocaval/splenorenal/mesocaval shunt or splenectomy.

    Do we know the MELD score? Or the Child-Pugh score?
     
  6. roja

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    Yeah, she had gotten 14 units, plus ffp/plts in about 5 hours. No uop. It was as if we were pouring blood into her stomach and it was just coming out her mouth.

    The blakemore slowed things down but the surgical resident and attending on that night just kind of gave me a 'what would we do with that?'. GI had already scoped her and basically said they weren't going to do anything.

    (I think she had portal vein thrombosis as she wasn't an ETOH-er and never had liver problems before). TIPS made sense but IR wouldn't come in and she wasn't really stable to go anywhere but possibly the OR.

    I did some reading and it seemed basically like a surgical wreck. GI saying they saw tons of esophogeal and gastric varices but couldn't isolate the source due to to much blood.
     
  7. SLUser11

    SLUser11 CRS

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    That sounds more like the treatment for a bleeding ulcer than uncontrolled variceal bleeding. In my experience, which I admit is limited to 2 years, you can control the vast majority of these bleeds with sclerotherapy or banding. If that's unsuccessful, you go to the Sengsten-Blakemore tube (sp?), which I've only seen once.

    If they fail the tube, they're pretty much SOL, but the surgical treatment of this would be TIPS, not vagotomy,etc. There are some other shunts I'm less familiar with....
     
  8. roja

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    Por favor, enséñeme. (Please, teach me) I am not familiar with these scores.
     
  9. SLUser11

    SLUser11 CRS

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    Sorry, I didn't see this post when I was typing. Pretty much I just repeated what you said.:D

    Any way you look at it, that patient is likely dead now. Bummer, but an excellent teaching case.
     
  10. The MELD (Model for End-stage Liver Disease) score plugs the patient's creatinine, bilirubin and INR into a formula...this can quantify the severity of liver dysfunction. In the acute setting, it is also helpful for active variceal bleeding as it can predict mortality.

    The Child-Pugh classification looks at bilirubin, albumin, PT increase, presence of ascites and/or encephalopathy as a way of estimating mortality, morbidity and risk of variceal bleeding.

    Let me see if I can figure out how to insert a table...
     
  11. roja

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    NY state is tortorous for attending surgeons I think. It makes them INCREDIBLY resistant to taking really really sick and moribound patients to the OR. (any death on the table has to go through a full investigation, which I imagine is an incredibly annoying process).

    She ended up getting really brady and then died before it became an issue. It just brought up some interesting thoughts for me.... (I have long hated our general policy that surgery get consulted on all Lower GI bleeds, regardless of stability, etc...) Mainly the question I try and always ask myself and residents: what is a consult going to offer me? because if its just CYA or I don't want to deal with it, these are crap ass reasons to get one. In the ED, you get a consult because you need someone to do something that I am not trained to do: like take a hot gallbladder or appendix out. Not make the diagnosis. (/rant)


    As a resident, I was on CCU and recieved a patient from our downtown site with known Aortic Dissection. She was hypertensive but stable. All of a sudden, she sat up, started screaming about chest pain and her pressure TANKED. I know she was either progressing her dissection or had ruptured. Tried to get CT surgery involved (but my resident was a little timid) which was ignored. In the AM (some how she survived) the CCU attending did a stat TEE and we saw the rupture wiht blood in the mediastinum. Still had to twist CT surgeries arm to take her to the OR. I am sure its because they knew she would likely die on the table (she didn't).
     
  12. Nope, couldn't figure it out. I'll just have to list it out:

    Child-Pugh Classification

    Ascites
    1: Absent, 2: Slight, 3: Moderate

    Bilirubin
    1: < 2, 2: 2-3, 3: > 3

    Albumin
    1: > 3.5, 2: 2.8-3.5, 3: < 2.8

    PT increase
    1: 1-3, 2: 4-6, 3: > 6
    (can also use INR: 1: < 1.8, 2: 1.8-2.3, 3: >2.3)

    Encephalopathy
    1: None, 2: Grade 1-2, 3: Grade 3-4

    ***

    So add up all the points, and you get...
    5-6: Grade A (well-compensated disease)
    7-9: Grade B (significant functional compromise)
    10-15: Grade C (descompensated disease)
     
  13. roja

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    But will either of these change if you take the patient to the OR? (assuming you would take this person to the OR.)

    She was an acute liver failure (no previous hx) so do these apply?

    I guess what my question is: in the really acute setting (Acute renal failure, hypotension, tranfused multiple units, intubated, with messed up coags and LFT's) her mortality is almost certain. Are these predictors going to help you decide what to do with the patient? What if the family 'wants everything' (which they did as she had been walking/talking the day before)
     
  14. roja

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    I googled it. :) as an addendum to my previous post, is there a clinical context these are used in? Like ranson's? (needing to be 24-48 hours out and thus not helpful to me in the ED)
     
  15. And then using the Child's score...

    Grade A: 100% 1-year survival, 85% 2-year survival
    Grade B: 80% 1-year survival, 60% 2-year survival
    Grade C: 45% 1-year survival, 35% 2-year survival
     
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  17. roja

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    This is the problem with these for me clinically. (and i probably slightly off topic.) One year mortality is somewhat meaningless to me in the acute setting. the patient is bleeding out in front of me, and walked in to the ED. More of use, at least to me (because its really all about me....:D) is what is the chance she is going to live through the next 24 hours? Through some surgery?
     
  18. Winged Scapula

    Winged Scapula Cougariffic!
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    Those GIB consults always used to bug me too. "Patient's stable, but my attending wants surgery 'on board'".:rolleyes:

    Since the vast majority of time in our patient population, surgery was never needed to do anything, my feeling was that the consult was a waste of time and if you actually thought the patient needed to go to the OR, THEN call. We can figure out everything we need to know - how many units, current status, tests done, etc. in the time it takes to prepare the OR.

    Your lady sounds pretty horrific. Probably needed a splenectomy and shunting if TIPS was not available or appropriate (ie, she wouldn't have follow-up), although I can see why the surgeons would be reluctant; pretty high mortality rate. Some surgeons are aggressive and will do whatever the family wants, despite the odds and others will refuse (but still have to refer the patient).

    She is the patient the Surgery boards love to ask about - ie, I've never actually seen a patient who needed a shunt but for some reason they ask a lot of questions about them.
     
  19. I thought the classic Boards question was:

    "You have a patient with colon cancer and a AAA. Which do you operate on first?"
     
  20. roja

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    Alright, I am going to show my surgical ignorance here: how does the spenectomy help and what are you shunting? Are you bypassing the portal vein? (assuming this is the problem?)



    I so agree with you regarding the consult issue. I am amazed I didn't get in more trouble, because I pretty much refused to get surgical consults on a non-operative GIB (in essence, someone who needed an EGD and colonoscopy). I just made a choice to ignore the 'policy'. I also didn't consult surgery for 'suspected' appy that I knew would need a CT scan (ie not the classic young male presentation that I though MIGHT be able to not get a CT scan) despite many of my colleagues doing this.

    In essence, I call surgical consults when I need a surgeon to do something a surgeon could do. (although in my hospital, really bad pancreatitis, particularly biliary, I would get a surgical consult because they manage these patients better in my previous hospital.)
     
  21. Winged Scapula

    Winged Scapula Cougariffic!
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    That IS another ( I do recall getting that one). I guess for me the shunts stood out more because I was complaining about them to a friend because I had a such a hard time memorizing them, having never seen one, and of course, I got like 5 shunt questions.
     
  22. Winged Scapula

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    The choice of procedure somewhat depends on what the cause of her bleeding is although you could make the case in someone like her to "fix now, ask questions later" because she is obviously dying.

    About 1/3 of initial GE variceal bleeds are fatal (hence the reason for knowing what to do when the S-B tube doesn't work or you don't have TIPS).

    If she was a known cirrhotic (and it sounds like she wasn't), its not suprising she would develop portal HTN with venous collaterals and portosystemic varices. Even in patients without cirrhosis, pHTN can develop with PV or hepatic vein thrombosis (liek Budd-Chiari Syn).

    Most patients (as I recall, like 80%) are supposed to get better with octreotide, EGD and banding = sclero with fewer complications.

    Splenectomy plays a role with patients who have bleeding gastric varices unreponsive to the above. Since they are deeper in the submucosa these are the patients who present like your lady. The stomach varices are usually secondary to pHTN with cirrhosis or from splenic vein thrombosis (most common cause of which is chronic pancreatitis). Splenectomy eliminates the collateral blood flow to the stomach.

    TIPS really is the procedure of choice for patients with bleeding gastric varices but it requires coordination with IR, Rads and the patient has to be compliant with follow-up (ie, you can't really TIPS someone who lives in the hills). But patency rates are great although encephalopathy is a concern in chronic liver failure patients.

    A portosystemic shunt is no longer the primary treatment of these patients given the efficacy adn availability of TIPS. But there are situations in which TIPS is not available or doesn't work or the patient is too unstable and emergent shunts are needed in patients with Childs-Pugh Classes A & B (I think most people would not place them into Class C given the mortality rate).

    The shunt of choice in an emergency is generally a portocaval or mesocaval shunt which decompress the entire portal system In the former, you essentially transect the portal vein at the hilum and plug it into the IVC so the portal blood is shunted away from the liver. Guess what the major complication is if you shunt portal blood from the liver? Patients also get hepatic encephalopathy more frequently with these "non-selective shunts". The mesocaval shunt is basically the same thing but rather than transecting the PV, you open up the anterior wall to get to the posterior wall and anastomose that to the IVC, closing up the anterior venotomy.

    Selective shunts only decompress the GE bed and thus have far fewer hepatic complications by maintaining blood flow through the liver. But these are much more technically challenging and while may be best for the patient, in an emergency you want to get in and out quickly. The Warren (distal splenorenal) shunt is probably the most commonly used. Basically by shunting the blood away from the high pressure systems, you are reducing if not eliminating the bleeding.

    At any rate, depending on her Child's class, emergent operations can have up to 80% perioperative mortality, so I'm not suprised that local surgeons and IR didn't want to touch her. Hope the above explains it.


    How come you never worked in any of my emergency rooms?! :love:
     
  23. dynx

    dynx Yankee Imperialist

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    A couple of thoughts:

    1. If the patient is hypotensive due to bleeding and on pressors they are not stable. This shouldn't happen, you can either recussitate a bleeding person with fluid/product and see if they stop bleeding (like a responder from a damaged spleen in trauma) or they are bleeding at a rate you cannot keep up with and need to have the bleeding stopped by IR/endoscopy or the OR. Having this person on pressors in the ICU is waiting for them to die, which is okay if the family is on-board but if you are doing "everything" pressors without a plan for immediate action is "nothing" at all. It's unaceptable that this situation occured if it is as you described.

    2. If the thought was portal vien thrombosis (CT scan? or was she too unstable from the get-go? then get an US) the OR w/ a peripheral shunt should be on the list of options. TIPS diverts flow in the liver, if the portal flow never reaches the liver its not likely to work but thier have been some case reports where it is sucessfull if the portal vein thrombosis is only partially occlusive and the thrombosis was also due to cirrhosis (resistors in series). A mesocaval or spleenorenal shunt could work.

    3. This is a salvage case, as a last resort you can do a stapled transection of the esophagus, leave the abdomen open, recusitate the patient and take them back later.
     
    #21 dynx, Jun 21, 2008
    Last edited: Jun 21, 2008
  24. SocialistMD

    SocialistMD Resident Objectivist

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    Thank you. I was scrolling all the way through hoping to see this answer. Shame that it took to post 21.
     
  25. (1) Very true.

    (2) Damn! Forgot that one. You're absolutely right - divert, silo, come back to fight another day.
     
  26. roja

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    What do you do with a patient whose has two cordis lines with units being transfused on each through a rapid transfuser, a blakemore tube, IVF on pressure bags in two 18g IVs and on dopamine and transport them to an IR suite? Or is the point unacceptable that the patient didn't go immediately to the OR? I'm just confused about your point.

    No imaging was done. Pt was to unstable to go anywhere (CT or ultrasound... see above). Interesting stuff on the different shunts. (I really don't think this would have worked on this patient but it brings up interesting points of what to do if she had been a little more stable)




    Ooooooooooh, very cool. I have never heard of this.:cool:
     
  27. Winged Scapula

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    Clearly she was too unstable for TIPS or anything more than a salvage operation. dynx's point, if I may, is that surgical teaching is that a bleeding unstable patient should be in the OR. Any other option is to accept that you are letting the patient die (which, if she was a Child's C, is probably inevitable).

    And while the issue of shunts, splenectomy, TIPS is interesting and is an option for many, for your lady stapling off the esophagus and perhaps placing a GJ tube is the best option (although again, with such a high mortality many would not even attempt this).
     
  28. core0

    core0 Which way is the windmill

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    The real issue with Child's is surgical mortality. Your surgical mortality with anyone with Child's C is pretty much 100%. Even with Child's B its probably around 50%. Child's-Pugh is considered to be a better way to evaluate surgical mortality than MELD (pretty much its only use these days).

    Actually its not acute liver failure by definition. Varices (especially as extensive as those you describe don't occur over night). This is some sort of chronic liver disease (potentially with an acute component on top - so called acute on chronic). Just because there was no history of liver disease doesn't mean that they don't have chronic liver disease. Variceal bleeding can be the first presentation of liver disease in up to 20% of patients.

    Usually EGD >>> Octreotide >>> Blakemore tube (if you can find it) is the standard course. If you can stabilize them and the bleeding doesn't stop you could consider TIPS if your patient is stable enough.

    As far as the surgical consult, I can tell you in five years of private practice GI we never called a surgical consult on an UGI bleeds. I think the response would have been the same thing they told you. On the other hand we would frequently call consults on brisk LGI bleeds. Its really a matter of courtesy. If you are going to have to call surgery in the middle of the night, its nice to give them warning and let them assess surgical risk during the daylight.

    David Carpenter, PA-C
     
  29. Totally agree. :thumbup:
     
  30. dynx

    dynx Yankee Imperialist

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    This is exactly my point and its important. Pressors for a bleeding patient are used for one of two things:
    1. Keep the brain perfused while you get ready to stop the bleeding (OR/IR etc...)
    2. Make yourself feel better while they die.

    YOU NEED TO UNDERSTAND THIS. If a chief resident let the above situation happen where I train they would be crucified. A BLEEDING PATIENT ON PRESSORS (if a full code) needs to be moving towards some sort of definitive therapy. In this case the chick was likely going to die anyway. But, you will see (I asssure you, i've seen it twice) someone put a bleeding patient on pressors so that they later cut off thier necrotic hands and feet. You're not helping them.

    The above lady had a chance (a slim one). The OP asked "what do you do?" well, you transfuse, you load with fluid, you add pressors but you then move them towards definitive treatment which in this case is likely transection.

    All I want you to realize is that pressors for a bleeding patient means death. Period. Again, thats okay, as long as you realize it. If thats the plan then carry on....but don't think you're saving them.
     
  31. dpmd

    dpmd Relaxing
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    Another point I just thought of. At some point in this someone needs to take a step back and decide the "do everything" is no longer appropriate. That becomes easier if the appropriate consultants are on board and agree with your assessment that intervention is either not going to help, or might help but at too high a surgical risk (and yes, some surgeons are less willing to risk a death on the table for a possible decent outcome, especially when there is likely a rocky post op course even if they do survive). Then you talk with the family, and prepare them for things. You shouldn't exhaust the blood bank for a patient that has no plan for definitive treatment of their problem.
     
  32. roja

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    Having been an attending for a while, and in a combined ED census of 180K/year, I'm quite aware of what this means. :) My question wasn't "what do you do" it was more, what is the role of a surgical consult (ie, is there a definitive surgical treatment), as our surgical service seemed to feel there was no other option other than what we were doing. (especially as TIPS was out of the picture because she was to unstable).

    In this patient, pressors and transfusions were being used not as definitive treatment, but as a stabilizing, stopgap until a definitive treatment (if one existed) could be found. I am not so inexperienced to think that pressors in a bleeding patient is a solution. :)

    You raise a great point about 'making yourself feel better'. I teach a ton of critical care and this is a point I reiterate over and over: You aren't here to make yourself feel better. You are here to help your patient. So, think about that when you are placing orders. A morphine drip and supportive therapy is much better than doing something you know isn't going to work but you feel that you have to do 'something'.


    dtmp- this is such an important point. I have led several critical care conferences around this exact issue. It actually amazes me how rarely the concept of medical futility is discussed among residents. That as a physician, you can say to the family, we aren't going to proceed any further. In this case, the patient semistabilized enough to try start trying to find some definitive treatment. Unfortunately, she crashed so rapidly that there was little time to have that discussion. We ended up calling the code after an hour of resuscitation.
     
  33. roja

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    I knew it was a mess no matter what. I imagine what the attending was communicating through the resident (I love the 'telephone game' where less and less is transmitted down the line) is that there might have been options but none of them really very good. I don't blame them for not wanting to take her to the OR. I was just curious, from an academic standpoint, of what MIGHT have been possible. Thanks for all the insight. :)

    (and I would come work in your ED *anytime*. :D )
     
  34. Hamilton Bailey

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    I am surprised no one mentions esophageal transection/stapling to be an option for this patient who apparently has non cirrhotic portal hypertension possibly due extra-hepatic PV obstruction...(CLUE: "language barrier")
    That will take care of the collaterals to the esophagus (from the stomach and rest of the high pressure mesenteric circulation) and stop the bleeding from the esophageal varices...
    IT IS possible to miss esophageal varices (on a UGIE) in patients who bleed torrentially!!
    Additionally the gastric varices (if present) can also be excised (esp if they are in the fundus)!
     
  35. Winged Scapula

    Winged Scapula Cougariffic!
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    It was mentioned...
     
  36. Hamilton Bailey

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    I guess its because the words "esophageal transection" got lost in the huge posts #21 and #28 :p
     
  37. Winged Scapula

    Winged Scapula Cougariffic!
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    Yes, we were quite wordy weren't we?

    Almost medicine like in our discussion of shunts, TIPS, etc.:p
     
  38. tussy

    tussy Senior Member

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    Surgery is often consulted for patients where I work as well. Usually it is because they are about to call it futile to do any further resuscitation and just want to have everyone on board to make sure that there are no other options that hadn't been considered. Not unreasonable really.
     
  39. ESU_MD

    ESU_MD Old School

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    has anyone ever scrubbed on a shunt procedure?

    Does anyone outside of the boys in Florida do them? (besides everyones "oldtimer" who did hundreds)
     
  40. Winged Scapula

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    Nope...never seen one; not sure if I ever saw one on the schedule as a resident or fellow.

    Despite that, ABS likes to ask about them.
     
  41. droliver

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    I think I did 3 or 4 during residency, mostly on the transplant service which had some of these smoldering ESLD patients. It's a lot harder then it sounds as you're doing the anastamosis way down in a hole with porto-caval procedures. What was really interesting on one patient who kept clotting off her graft is that you could tell when her shunt was working by how crazy (encephalopathic) she'd get.

    I actually got asked a shunt scenario on my oral surgery boards and had to go over a couple different shunts and their specific morbidities. One more useless piece of trivia I no longer carry around on board!
     
  42. dpmd

    dpmd Relaxing
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    I didn't scrub on the procedures, but here in little old Bakersfield, CA there have been at least three in the past year. Then again our chairman (chairwoman?) is a transplant trained hepatobiliary surgeon.
     
  43. We have an old-school guy here who still occasionally gets called to do a shunt. Splenorenal and portocaval mainly.
     
  44. maxheadroom

    maxheadroom Rhinestone Cowboy
    Moderator Emeritus

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    I saw a portocaval shunt as a medical student. One of the scarier procedures that I've ever seen. Deep, deep hole and lots of blood.
     
  45. lirgo87

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    Hi All

    I just happened upon this site googling for Humira info.

    I am going to be your worst nightmare and maybe a more interesting case. I started Pre Med and ended up being medically filled with info(crohns for 30years) as well as a speech language pathologist(couldnt cut it with the crohns).

    I had received a spleeno renal shunt at age 38(now42). I was told all over the country and basically the world(I do my research and contacted anyone, when you're told at 35 you may die if....San Diego, Chicago, Boston, Philly, London) to be preped for a liver transplant. THIS was NOT the way I, my Gastro nor a few others in the old school know wanted to go.

    I had multiple non bleeding varices(seen during ERCP's-suspected were Caroli disease and PSC), normal liver work ups, non drinker-few times a year and light. I 've had crohns for hmm 30 years. 2 previous abdominal surgeries, one an abscess, cholecystectomy but still get "sludge". I develop sepsis whenever something invasive is done so I require vanco pre anything, otherwise I have a home IV plan for 6 weeks. I had NO symptoms; they were just concerned because I could "blow" at any time :) Have to laugh, otherwise you may cry!:laugh: Oh meds are many-I'm prednisone dependent(now have two total shoulder replacements (UGH there goes my golf game-for now!), I have an odd unknow left leg swelling-pitting edema so take a small dose of lasix,potsssium because of the lasix, ursoidol, 50,000 units of Vitamin D and calcium supplements-beginnings of osteo but I'm ahiking walking fiend-so it's at bay,atenolol for migraines, multi vitamins because I'm malnourished from the crohns. YAY!

    At a local well known hospital, I was told to go home because I "looked too healthy"-they expected some withering gray, on their last leg woman and thats just not my style. I always look fairly healthy-ish once you get passed the thin and small stature. They pretty much said wait til you bleed and then we ll figure out what to do fast. Uh, too late for my book if ya ask me.

    Mayo Clinic! I kept in contact with a tremendous in his field ERCP man who left Yale for Mayo. He helped set up a team. I DO my homework. I KNEW I would need a tag team-hep, gastro and vascular. THEY were the only ones who showed me SUCH great confidence, security, what have you , in taking my life into their hands. I am a VERY positive person with all I have so far lived through, so for a doctor to tell me, "you could die" does NOT register. And I KNOW you have to do it but there are gentler ways of saying such??? They didn't. They knew I already knew my options and why I was there.

    IF you get the chance to see this( I was tagged teamed with a stricturo plasty guy-so LONG surgery)I'm sure its quite amazing.

    I call myself patient X. I'm in th eprocess of writing a book, more for those who HAVE crohns but could be an eye opener for some doctors too.

    Always think outside the box(I work with autistics-we re ALWAYS outside the box:)) When you think you ve got the Only answer, look one step more. ANd don't laugh at that old time doctor and his old time theories-He may just have something there! Everything seems to come back around even in my field.

    I hope I havent over stepped my boundaries. I just want you to be IN the KNOW. WE are out there. Even at odd ages and may show NO symptoms. I have been told MANY times by doctors I am an enigma of science...I call it lucky to have such faith and God alway sgetting me through-he brings me to the right good people-You guys!

    Keep up the good work and keep looking one step beyond! Luck to you guys!
     
  46. dynx

    dynx Yankee Imperialist

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    Im so sure that I want to respond and yet Im going to have to wait for the translation to be posted.
     
  47. Winged Scapula

    Winged Scapula Cougariffic!
    Staff Member Administrator Physician Faculty Lifetime Donor Classifieds Approved

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    Translation:

    there are young, otherwise healthy people in the community who are doing well s/p splenorenal shunts and without being listed for OLT.
     

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