Constant vomiting...please read and brainstorm!

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I'd Rather Be Riding
Regular Member


Date Joined Apr 2010
Total Posts : 149
   Posted 5/27/2011 7:45 AM (GMT -6)   

Hi Everyone,

 

I need all the fresh eyes and opinions possible on this one for Lizzie. To recap, she has had seven major abdominal surgeries; primary diagnosis was colonic inertia, then rectal inertia. She had a total colectomy, emergency ileostomy, reversal, K-pouch (which failed), K-pouch revision (also failed), end ileostomy, then they had to move her stoma to the left side of her abdomen. Her last surgery was at the end of November 2010. For awhile, she was having surgery every three months. After her last surgery, she was able to eat better, but soon every bite caused severe nausea, distention, and all the symptoms of an obstruction. The ER would X-ray or CT and not find one. They did a feeding tube (PGJ) for about two months, and she was able to start eating by mouth again with minimal symptoms. The tube was removed, she did ok for another month, and now things are horrible. Two bites of anything will cause distention, nausea, and vomiting. She eats extremely bland and still can only keep a couple hundred calories down every day.

 

On Wednesday they did an MR enterography (basically a gut MRI after drinking contrast), and it was negative for kinks, twists, strictures, or narrowings. Insert complete and total confusion here!!! She is miserable and just wants to be able to live and keep food down. A new internist ran a ton of labs last Friday...we don't know those results yet, but he checked CBC, CMP, albumin, all B vitamins, vitamin D, thyroid, and several other things. He felt that she would probably need TPN; she hasn't had her follow-up with him yet, though.

 

So, my question is: does anyone have ANY ideas?! Has anyone experienced this or anything like it?? Any ideas are GREATLY appreciated!

 

Thank you so much!

 

Allie

 

Constant vomiting...please read and brainstorm!


CrohnsPatient
Regular Member


Date Joined Feb 2008
Total Posts : 314
   Posted 5/27/2011 9:11 AM (GMT -6)   
I dont know whats causing this but it sounds as if she needs tpn atleast for the time being if she is only able to keep down a couple hundred calories, loosing a lot of weight I can imagine wont help what so ever.

2much2bear
Veteran Member


Date Joined Mar 2008
Total Posts : 624
   Posted 5/27/2011 9:39 AM (GMT -6)   
Hi,
 
Thing is, it is hard because if the drs don't know then what else is there?  May be a new consultant and new hospital??
 
What about gastric emptying - i expect she has had that and testing her oesophagus -  just a guess. Lizzie has been really brave. x
 
 
Karen: 49 years old
1997: Diagnosed IBS
2003: Pelvic Floor repair
2006: STARR procedure - mucosal prolapse/ODS/diagnosed slow transit constipation
2007: Sigmoid resection (MRI showed twist) - made colonic inertia worse (cleared obstruction though)
March 2009: Total colectomy with ileorectal join and loop ileostomy
23 Sept 2010: Ileostomy reversal - not going well

2b ColonFree
Veteran Member


Date Joined Nov 2008
Total Posts : 2603
   Posted 5/27/2011 10:09 AM (GMT -6)   
breaks my heart hearing about Lizzie's condition :((( i'm just so sad for this girl! i truly have no idea what to advice.. we can only pray for her. love you dear, worried about you.. :'-(
Hodaya
06/05/2007 - STARR procedure
colonic inertia w/pelvic floor dysfunction
08/16/2009 - total colectomy w/ileorectal anastomosis
07/08/2010 - loop ileostomy

Bay Area Guy
Regular Member


Date Joined Jul 2010
Total Posts : 301
   Posted 5/27/2011 5:55 PM (GMT -6)   
I'm not sure if this would help or not, but it might identify anything internal that the MRI didn't see. Perhaps a colonoscopy and endoscopy would be able to shed light on what's going on. At the very least, it could rule certain things out and, as is the case with so many things in life, knowing what it's not could better lead to finding out what it is.

pelztier86
Regular Member


Date Joined Apr 2009
Total Posts : 401
   Posted 5/28/2011 3:52 PM (GMT -6)   
I'd guess it's the same mechanism that took place after her kock pouch surgery and before her tube. i think one has to think over why she did pretty well with the tube as she could even eat some orally.
on an emergency x-ray it's sometimes difficult to tell whether it's a functional obstruction or a true/mechanical.

i cant help but wonder why she did well on tube feeding while she was worse before and is now. sure it could be that her small bowel is dysmotile but the problem i have with this idea is: she would not have tolerated the tube feedings, at least with a pretty severe dysmotility which the severity of symptoms would suggest.

so my idea i still: adhesions. we know she seems to get them easily. adhesions do not have to show up even on MRI etc images when they do not form a clear stricture/stenosis etc. many times adhesions do not cause this but cause the bowel loops to stick together and to be glued to the mesentery hindering the loops from moving freely.

with adhesions that do not cause a real permanent obstructions (like those causing strictures etc) one can be fed enterally through a feeding tube. it may even help to stimulate the loops to move which could explain why she could eat one tube feedings.

another rather simple option would be severe gastroparesis but i would guess that this has already been ruled out..?

there is also such a thing like cyclic vomiting syndrome which is poorly understood but has more to do with the brain. however, usually people with cvs have ups and downs, flares andperiods when they dont vomit at all. yet, there is a wide range of clinical picture.

pelztier86
Regular Member


Date Joined Apr 2009
Total Posts : 401
   Posted 5/28/2011 4:33 PM (GMT -6)   
just another quick thought: constant vomiting after eating/drinking can also be caused by SMA syndrome. basically the superior mesentery artery compresses the duodenum which caused an intermittent mechanical obstruction. it is difficult to diagnose, even on high resolution images. i think the ankle between the sma and the duodenum is measured as an indirect evidence for this syndrome. as always with rare issues it is absolutely important to find a specialist. there are some issues that can predispose to the development of sma syndrome if its not congenital. surgery may be a cause, or rapid weight loss, vascular abnormalities etc. though it has primary intestinal symptoms sma syndrome is actually a vascular disease.

it might be that bypassing the duodenum with a PEJ would resolve the problem and helps the duodenum to keep open so that she could eat orally. i think it would be worth to test her for sma syndrome.

pelztier86
Regular Member


Date Joined Apr 2009
Total Posts : 401
   Posted 5/28/2011 4:37 PM (GMT -6)   
Introduction
Superior mesenteric artery syndrome (SMA syndrome, also known as Wilkie's syndrome,) is a rare condition first described in 1861, by Rokitansky (1). It occurs when the third (transverse) portion of the duodenum gets entrapped under the superior mesenteric artery. Anatomically, the duodenum passes across the abdominal aorta just below the origin of the SMA. In some cases, various structural anomalies change the angle between the superior mesenteric artery and the aorta (which is normally 45°). This change creates pressure to the duodenum, resulting in to obstruction of its lumen. In the English-language medical literature, there are over 400 cases of SMA syndrome reported, constituting this an unusual cause of upper intestinal obstruction. Some researchers and physicians however still doubt the syndrome's validity (2-6).

Pathophysiology
The SMA usually forms an angle of approximately 45° (range, 38-56°) with the abdominal aorta, and the third part of the duodenum crosses caudaly to the origin of the SMA, coursing between the SMA and aorta. The SMA usually arises from the anterior aspect of the aorta at the level of the L1 vertebral body. It is enveloped in fatty and lymphatic tissue and extends in a caudal direction at an acute angle into the mesentery. In the majority of patients, the angle between the SMA and the aorta is about 25 to 60 degrees, due in part to the mesenteric fat pad. In the SMA syndrome, the angle is reduced to as low as six degrees due to the loss of the mesenteric fat pad, allowing the SMA to compress the duodenum against the aorta. Any factor that sharply narrows the aortomesenteric angle to approximately 6-25° can cause entrapment and compression of the third part of the duodenum as it passes between the SMA and aorta, resulting in SMA syndrome (7-10).
In addition, the aortomesenteric distance in SMA syndrome is decreased to 2-8 mm (normal 10-20 mm). Alternatively, other causes implicated in SMA syndrome include high insertion of the duodenum at the ligament of Treitz, a low origin of the SMA, and compression of the duodenum due to peritoneal adhesions (11).
Such causes as mentioned above are:
1. Constitutional factors: thin body build, curvature of the spine or laxity of the abdominal walls with a drop in the position of the internal organs,
2. Rapid or severe weight loss in conditions such as cancer or extensive burn injuries, prolonged bedrest, anorexia, or malabsorption syndromes (12-17).
3. Disease deformity, or trauma to the spine or anatomical variants (18-22).
4. Use of a body cast in the surgical treatment of scoliosis or vertebral fractures.
SMA cases after corrective spine surgery, are due to the result of spinal elongation, which decreases the superior mesenteric/aortic angle. Postoperative weight loss is an important factor for the development of SMA syndrome. Although the use of Harrington rods for corrective surgery commonly used in the 1950s and 1960s was an important contributory factor for development of SMA syndrome, newer derotation/translation corrective techniques can also be rarely associated with this disease entity (23-27), as rapid growth without proportional weight gain (particularly in teenagers) (28).
Other rare but recognized causes include trauma or aneurysm of the SMA, and familial predisposition toward SMA syndrome (29,30).
Furthermore anatomic anomalies as abnormally high and fixed position of the ligament of Treitz with an upward displacement of the duodenum or unusually low origin of the SMA.
Also, other unusual causes: traumatic aneurysm of the SMA after a stab wound, familial SMA syndrome and Recurrent SMA syndrome (30-34). Finally, SMA syndrome has also been described in pregnancy, when the gravid uterus reduces in abdominal volume (30).

Physical findings in SMA syndrome are often vague or generalized and the diagnosis of this condition often comes by exclusion. about eight out of ten patients are thin and sickly (asthenic habitus). They often suffer from peptic ulcer disease (25-45%), or hypersecretion of stomach acid (hyperchlorhydria). The presentation can mimic that of subacute small bowel obstruction. Examination can reveal tenderness or pain, fullness, or a succussion splash. Pressure from below the navel upward and toward the back (Hayes maneuver) can lift the SMA, releasing the obstruction and cause relief of both subjective and objective signs. Repositioning during the examination may also afford symptomatic relief.
As it was previously reported the definitive diagnosis of SMA syndrome is difficult. Xray and other imaging studies that may be helpful include (46-51).
Upper GI study with barium contrast - can show dilatation of the first and second portions of the duodenum with a sudden cutoff around the midline.
Computed tomography (CT scan) of the abdomen is useful in the diagnosis of the SMA syndrome and can provide diagnostic information including the aorta-SMA distances and duodenal distension. It can also be used to assess intra-abdominal and retroperitoneal fat. Another diagnostic tool is fluoroscopy with contrast.
Upper GI endoscopy (esophogastroduodenoscopy) may be necessary to exclude mechanical causes of duodenal obstruction. However, the diagnosis of SMA syndrome may be missed with this study.
Finally, abdominal ultrasonography may be helpful in measuring the angle of the SMA and the aortomesenteric distance.

esoR
Veteran Member


Date Joined Jan 2007
Total Posts : 4147
   Posted 5/29/2011 2:41 PM (GMT -6)   
Alli,

I am on a computer inn Geneva. Am finally getting caught up on Healingwell. Hodaya and I met and toured in Israel and it was FABULOUS!

My heart breaks for Lizzie. There is a test called a CT entrcolysis which is more accurate than CT enterography. The entercolysis HAS to be done by a VERY experienced radiology doctor. I had it done at the Mayo Clinic. It shows very fine adhesion strictures that the CT enterography cannot due to the way it is done. NOT pleasant but this girl is in TROUBLE. They put in a very thin NG tube then thread a wire through it and guide it down through the stomach and out into the small intestine then they remove the wire with the tube in place NG into small intestine. Then they put in contrast and IV contrast. The only pain I had was residual pain from the wire from where it passed down through my trachea BUT it found the compression of the two small bowel loops. After as many surgeries as Lizzie has had there has GOT to be adhesions. No human body can go through that. CC should take responsibility rather than leave her as they did but that is now beside the point. I do know that the Mayo Clinic does this test. Mine showed two small bowel loops that were compressed very low in the pelvis. The only reason they showed was that they infused much contrast and then did the IV contrast. I think their tech doctors are the best around. Dr. Pemberton was the colorectal surgeon who said it was too dangerous to lyse those adhesions and was just going to leave the adhesions (thus leaving me to forever vomit) BUT his office COULD give you the name of the Radiology doc who did my entercolysis; he was phenomenal and made an otherwise intolerable procedure bearable.

Glad you are still advocating for Lizzie. I think the reason she was OK for awhile was that with alll that gut rest the small bowel had for a temporary time unkinked itself but until those adhesions are taken down and a barrier put in she may have recurring trouble.

Hope your issue is doing as well as can be done. More later. Give Lizzie my love, Rosemary

Janiepain
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Date Joined Jan 2007
Total Posts : 662
   Posted 5/29/2011 9:13 PM (GMT -6)   
Oh my goodness.....I was so hoping Lizzie was feeling better by now. This just breaks my heart. Please let her know I'm thinking of her and praying she can find some answers soon. It seems like I keep writing that....it's just so unfair the poor thing has had her life on hold for so long.

Love you Lizzie!

Janie
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