A 33-year-old medical secretary comes to the physic Show more Case Study %u2013 Abdomen Presentation/History A 33-year-old medical secretary comes to the physicians office complaining of nausea and vomiting of bile-stained food with sensations of bloating belching discomfort and pain in the upper abdomen.

A 33-year-old medical secretary comes to the physic Show more Case Study %u2013 Abdomen Presentation/History A 33-year-old medical secretary comes to the physicians office complaining of nausea and vomiting of bile-stained food with sensations of bloating belching discomfort and pain in the upper abdomen.
These symptoms come on approximately one to two hours after meals. Following a respiratory infection she suffered a marked weight loss amounting to twenty-five pounds during the last six months. Since then her symptoms have gradually worsened. On inquiry she states that since adolescence she has had alternating periods of well-being and abdominal discomfort accompanied by vomiting. Since the recent aggravation of her symptoms she has felt very fatigued and has lost her appetite. She further states that when she has these attacks of pain and vomiting she can obtain relief by lying on her side or in the knee-chest position. Examination On physical examination we find a rather apprehensive patient of asthenic habitus particularly conspicuous since she shows evidence of recent marked weight loss. She has very flaccid abdominal walls and her liver kidneys and spleen can be palpated easily. As is common in asthenic individuals she has a marked lumbar lordosis. The epigastrium is rather tender but otherwise no signs of acute intestinal illness such as rigidity of the abdominal wall or indications of intestinal obstruction can be elicited. The patient is advised to seek admittance to the hospital for further studies. In the hospital a full-blown attack is observed which came on after a fairly large meal with a meat course and dessert. She was stricken with nausea and fairly severe cramping pain in the right upper abdominal quadrant. She vomited bile-stained food that she had eaten recently. The vomiting relieved her pain. Before the attack subsided the examining physician noted that the patient displayed tenderness and visible peristalsis in the right upper abdominal region. Radiographic study of the upright patient under the fluoroscope with a radiopaque meal shows rapid emptying of the stomach which permits exclusion of pyloric stenosis. The first three portions of the duodenum fill rapidly and are considerably dilated. Under active peristalsis the duodenum finally empties part of the barium into its fourth portion but there is marked indentation of the barium filling at the site of transition of the third and fourth lumbar vertebrae. This corresponds to the cutoff point at the time of the beginning of filling of the duodenum. X-ray examination six hours after the barium meal shows a marked and abnormal residue of barium in the duodenum. Discussion Thread Questions Obstruction of the third portion of the duodenum as a clinical entity is an interesting phenomenon. Enthusiasm for this diagnosis has waxed and waned since the disease was first defined in the mid-1800%u2019s. There are still authors who deny the occurrence of such an entity but the majority of clinicians are now convinced of its existence particularly when confirmed by radiographic evidence. Anatomists and pathologists have known for a long time that postmortem casts of the duodenum frequently show an imprint of the superior mesenteric vessels on the anterior wall of its third part. The equivalent of this imprint has been demonstrated in vivo by radiologic means as a filling defect in the same location. Define the third part of the duodenum. What is its relation to adjacent structures particularly the parietal peritoneum transverse colon mesocolon pancreas aorta and superior mesenteric vessels? It can be palpated to the right of the mesenteric root. This part of the duodenum which is also often called the inferior or horizontal portion is about three inches in length. It begins at the inferior duodenal flexure as the continuation of the descending portion and generally crosses the third lumbar vertebra. At its left extremity it becomes the fourth or ascending portion that terminates as the duodenojejunal flexure. The artery is accompanied by its vein as it passes over the third part of the duodenum to enter the mesentery and to supply the small and large intestines from the distal duodenum to the left colic flexure. The superior mesenteric vein drains the same area of intestine and courses to the right of the artery. Their relationship to each other is easy to remember if one keeps in mind that the artery arises from the aorta in the midsagittal plane while the vein drains into the portal vein in its course toward the liver which is essentially a right-sided organ. What is the relation of the superior mesenteric artery to the pancreas? In its course the artery is surrounded by the superior mesenteric nerve plexus. Since the artery runs posterior to the neck of the pancreas it is of course also posterior to the transverse mesocolon which arises from the anterior surface of the pancreas. It is worthwhile to keep in mind that while the origin of the superior mesenteric artery is cranial to the third portion of the duodenum the origin of the inferior mesenteric artery is caudal to this part of the duodenum. It is also easy to remember that the superior and inferior mesenteric veins which accompany the two mesenteric arteries both lie to the outside of the arteries i.e. closer to the lateral abdominal wall than the arteries. Since the duodenum with the exception of its first portion is a retroperitoneal structure its position is less variable than organs having a mesentery. Nevertheless it is surprising to observe that the duodenum is relatively mobile in vivo. Its location varies with body posture being lowest in the upright and highest in the prone position. It also changes with the degree of its filling and the state of contraction of the anterior abdominal wall. It descends with age. Thus the level of the third lumbar vertebra or of the disk caudal to it represents only a mean as a landmark for locating the third portion of the duodenum with the range extending from L2 to L5. How do you explain on an embryological basis the retroperitoneal position of the major part of the duodenum and the retrovascular location of the third portion of this viscus in relation to the super mesenteric vessels? The cardinal point of this discussion is of course the pathogenesis of the clinical entity exemplified by our patient. While normally the superior mesenteric vessels pass gently over the third part of the duodenum in our case we have to visualize the transverse duodenum as being markedly compressed as in a vise between the aorta and/or lordotic vertebral column posteriorly and the taut mesenteric vessels anteriorly. This happens if due to severe weight loss in an asthenic patient with insufficient abdominal muscular support the intestines drop caudally to an undue degree. Thus marked traction is exerted on the superior mesenteric vessels at the site of the mesenteric root. This can lead to acute or

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