NIGERIAN JOURNAL °/ MEDICINE Vol. 26 No. 4 October - December, 2017 IN THIS ISSUE ‘COMPARING THE EFFECTS OF HAEMATOMA BLOCK AND CONSCIOUS SEDATION IN ADULTS WITH DISTAL RADIUS FRACTURES. SONOGRAPHIC NORMATIVE VALUES OF CAROTID INTIMA-MEDIA THICKNESS IN ADULT NIGERIAN POPULATION. MANDIBULAR FRACTURES CAUSED BY SPORTS: A PROSPECTIVE CLINICAL STUDY OF 72 PATIENTS MANAGED IN TERTIARY HEALTH FACILITY. DRUG DEPENDENCE IN FEMALES: A THREE YEAR REVIEW OF PATIENTS IN ADMISSION AT AN ADDICTION TREATMENT CENTRE IN NORTH ‘CENTRAL NIGERIA. PREOPERATIVE INVESTIGATION OF OPEN HEART SURGICAL PATIENTS: ‘OUR CURRENT INSTITUTIONAL PROTOCOL (1) ‘COMPRESSIVE SHOCK RESULTING FROM GASTRIC DISTENTION AFTER ARTERIAL SWITCH OPERATION: A CASE REPORT. A NON-FUNCTIONING LEFT KIDNEY FROM RENAL TUBERCULOSIS ‘AND AREVIEW OF LITERATURE,NIGERIAN JOURNAL OF MEDICINE @ ss MEDIC Contents The Nigerian Journal of Medicine Board.and NARD Executive Committee. 307 Editorial Notices 08 \riting forthe Nigerian Journalof Medicine a ae8 Original Articles ‘Comparing The Effects Of Haematoma Block And Conscious Sedation In Adults With Distal Radls Fractures, Onuoha KM, Orimolade E.A, Onuohac£.0,Adegbehingbe 0.0, kem|.c wn 31 3 Media Thickness in Adult Nigerian Population, Owoeye SC Anicc, KenisSF, Ukaont BC, OdohG, Angbalaga a nnn ——-26 Mandibular Fractures Caused By Sports: A Prospective Clinical Study Of 72 Patients Managed In Tertiary Health Facility. Charles E. Anyanechi, Birch D.Saheeb Hand Hygiene: Knowledge And Practice By Health Care Workersin A Tertiary Health Care FacilityIn SouthEast Nigeria. NduAnne , Arinze OnyiaS.U, Aguwa EN. 320 a 328 Stipped capital Femoral Epiphysis: A Review Of 40 Consecutive Cases At The National Orthopaedic Hospital Enugu. Katehy AmechiLchenna, Dura Ndubuisitbere, Katchy SomtochukwtuChike nn 334 Prevalence Of Smear Positive Pulmonary Tuberculosis Among inmates And Staff Of Abakaliki Prisons, Nigeria. Eze NC, Azuogu3N, AgyiNA, Akarikel nnn mmm 398 ‘Medico-Religious Collaboration: A Model For Mental Health Caren AResource Poor Country OshodiV.0, OgboluE.R, Oluseun Peter Nubi, Ongjole A.T, ThomicroftG., AdeyemiJ.D nnn mas OralHealth Status And Treatment Needs Of AScreened University Population In Port Harcourt, Rivers State Dr. tlochonwu, Nzube Anthony, DrBraimoh, Omoigberai Bashiru oncennn amntennininintiiiiimamninimamei 353 Review Articles Psychoactive Substance Dependence In Females: A Three Year Review Of Patients On Admission At An Addiction Treatment Centrein North Central Nigeria. Duwap. Makput, Kingsley Okonoda, Yusufu Maigari, Christopher Piwuna, Dami Nantok, Francis Davou, Suwa GGoar, Friday Tungchama. nn enc 360 Preoperative investigation Of Open Heart Surgical Patients: Gur CarrentinsttutionalProtocol NwaforlA, Eze JC, EzembaN Chinawa JM, Onyekwulu FA, Nwafor MN cence cram srnnnenine non eternaitin inn an 366 Cose Reports ‘Compressive Shock Resulting From Gastric Distention After Arterial Switch Operation: ACase Report. EchiehChidibereP., Muthu Joth, wagboso C1, OgbuduS.0,,Eze, NJ, Echie, Cl reece ccna eee eee nae 978 ‘ANon functioning Left Kidney From Renal Tuberculosis And A Review Of Literature:A ase Report Effa EE, Okpa HO, Arie A, Salako BL Kadir S vs Extensive Central Nervous System Tuberculosis In A Hypertensive, Immunocompetent Patient: Diagnostic Challenges And Imaging Review: A Case Report Sabiu Abdu Gwalabe, Hamza Mustapha Ahmed, Yusuf Aliyu, Solomon Daniel Halil, Yakubu Bababa Shirama, ‘Auwal Suleiman ee 379 Challenges Of Hirschsprung's Disease Presenting In An Adult: Samuel © Ekpemo, Uchechukwu 0 Ezomike, Sebastain O Ekenze, Nig ian Journal of Medicine, Vol. 28 No, 4, October-December, 2017, ISSN 1115-2013,COMPRESSIVE SHOCK RESULTING FROM GASTRIC DISTENSION AFTER ARTERIAL SWITCH OPERATION: A CASE REPORT “Echieh, Chidiebere P, *Muthu Jothi, ‘Nwagboso C.1, ‘Ogbudu S.0, ‘Eze, NJ, ‘Echieh, C. ‘University of Calabar Teaching Hospital, Calabar, Nigeria 2Indrapratha Apollo Hospital, Delhi, India. SV Compressive shock Is an Important cause of reversible cardiovascular compromise. Abdominal causes of compressive shock have been known tobe dificult to dagnose, We report our experience in the management of ‘compressive shock resulting from gastric clstension, We conser gorte distension to be an unusual cause of ‘Compressive shock lmmedatereleofintraabdomninaltension skein he management NigerJmea2o17: 372-374 (© 2017. Nigeran Journal of Medicine INTRODUCTION S: is a state of acute circulatory failure leading to decreased organ perfusion, with ‘inadequate delivery of oxygenated blood to tissues and resultant end-organ dysfunction. It may result from hypovoleimic, distributive, cardiogenic or obstructive mechanisms’. These mechanisms inform the classification of shock. We present our challenges in the post- operative management of a newborn with transposition of great arteries managed by arterial switch operation, that was complicated by compressive shock resulting, from gastric distension. CASEREPORT Baby AS a first born male was born in a peripheral on cardiopulmonary bypass with high aortic and bi- cavalcanulation. Alpha stat technique was maintained. Post operatively, patient was maintained on pressure controlled assisted mechanical ventilation and later onsynchronized intermittent mandatory ventilation. Haemodynamic and oximetry parameters were normal When feeding was started on second postoperative day, abdominal distension was noted, central venous pressure rose to 20cmH20, ventilator requirement increased. Blood pressure and urine output dropped. X-ray of chest and abdomen showed a distended gastric shadow (figure 1). This episode was managed conservatively using diet restriction, nasogastric suctioning and intravenous fluids. Patient responded and parameters came to acceptable ranges. center at term via spontaneous vaginal delivery. Birth weight was 2.8 kilograms. Baby was noted to have cried at birth. Within 24 hours of birth, he was noted to have a bluish discoloration. Two-D echocardiography showed d-Transposition of great arteries hence patient was commenced on prostaglandin and referred to Apollo hospital, Delhi Age of mother at birth was 26 years. At presentation, baby was cyanosed, hypothermic, hypoxic and tachypneic. Echocardiography showed atrio-ventricular concordance and ventriculo- arterial discordance, patent foramen ovale with bidirectional shunt, muscular ventricular septal defect with left to right shunt. There was also a small patent ductusarteriosus with bidirectional shunt ‘An emergency atrial septostostomy was done for resuscitation, and patient was scheduled for arterial switch operation. Arterial switch operation was done Sjrstom of Carsiothorae Surgery, Deparment of Sangery ‘Universi of Calabar Teaching Hospital Calabar coll cochehgmailcom Figure 1: X-ray of chest and abdomen showed a distended gastric shadow Te zsso08 372 Nigerian Journal of Medicine, Val 26 No. 4, Oclobor- December, 2017, ISSN 1115-2613(On recommencement of oral feeds, the compressive features returned and X-ray of chest and abdomen doneat this time showed a beak at the pyloricantrum| (figure 2), Abdominal ultrasonography showed the pylorus with a single wall thickness of 0.33 cm, length of lem and the maximum pyloric lumen noted was 0.2cm. Patient was commenced on atropine at a dose of 0.05 mg/kg/day in 8 divided doses administered through the nasogastric tube at4 hourly intervals. Feeding was introduced and gradually increased. Sonographic follow-up showed improvement in| pyloric size and flow of gastric contents. Weight gain ensued, DISCUSSION Compartment syndrome is defined as an increased, pressure in a closed anatomic space, which threatens the viability of enclosed and surrounding tissue. It may occurin the cranium, thorax, abdomen or limbs. The abdominal compartment has unique effects because it is geographically situated 'up-stream’ from the extremities and ‘down-stream’ from the chest. Therefore, it may influence the physiology and pathophysiology of each of these other compartments” Pyloric Beak The clinical manifestations of abdominal compartment syndrome in a newborn following arterial switch operation may be mistaken to be compressive shock resulting from pericardial tamponade complicating the surgery. Inta-abdominal hypertension (IAH) has been defined as sustained repeated pathological elevation of intra-abdominal pressure 212mmHg, while abdominal compartment syndrome (ACS) is defined as sustained intra-abdominal pressure >20 (with or without abdominal perfusion pressure <60) that is associated with new organ dysfunction/failure These definitions were ratified at the 2004 International ACS Consensus Definitions Conference Abdominal causes of obstructive shock have been’ reported in literature. These case were difficult to diagnose, with one of them made post mortem, Clinical diagnosis of obstructive shock may be difficult in the absence of invasive pressure monitoring because elevated CVP with systemic arterial hypotension ischaracteristic. Itis difficult to make a case definition of abdominal ‘compartment syndrome in our patient because we did not measure intra-abdominal pressure. However, the extent of physiological derangement defines shock. ‘The Pathophysiology is that the increased abdominal pressure consequent upon gastric distension causes a restriction of venous return via the inferior vena ‘ava. Since the inferior vena cava accounts for two- thirds of venous return to the heart, cardiac output will ultimately be compromised hence the shock state. The drop in cardiac output can also be attributed to a diastolic dysfunction resulting from compressive forces on the heart. This explains the elevated CVP and poor tolerance of intra-venous fluid administration. The elevated intra-abdominal pressure will also splint the diaphragm accounting fortheelevated ventilatory requirements. ‘Our patient had an acute gastric outlet obstruction resulting from restrictive pylorus. ‘The factors that ‘may account for the restrictive pylorus in our patient may include mucosal oedema resulting, from generalized fluid retention following cardiopulmonary bypass or mucosal hypertrophy complicating prolonged Prostaglandin infusion. These factors may have acted in synergy and in concert with a borderline pyloric hypertrophy oF spasm. The history of prolonged infusion of Prostaglandin E1 raises the suspicion of hypertrophic pyloric stenosis since an association has been reported in literature. This suspicion is also supported by the finding of pyloric beak on plain abdominal X-ray. The deterioration to cardio-respiratory embarrassment was precipitous. This is as a result of mechanical ventilation which can account for gaseous distension of the stomach. Prostaglandin E1 (PGE) is used in ductal-dependant congenital heart disease to maintain the patency of ductusarteriosus. Hypertrophic pyloric stenosis 373 Nigerian Journal of Medicine, Vol.26 No. 4, Oclober December, 2017, ISSN 1115-2513(HPS) resulting from gastric mucosal proliferation is a rare complication of prolonged PGE infusion. In our patient, the pyloric stenosis and the post- operative mechanical ventilation resulted in accumulation of stomach gas resulting in significant cardiorespiratory embarrassment. Strict criteria for ultrasound diagnosis of hypertrophic pyloric stenosis, pyloric length of 16mm and single wall thickness of 4 mm, was not met, but itis our believe that thisis probably duc to early intervention. The clinical and radiological features of transient Hypertrophic Pyloric Stenosis following PGE infusion usually relieves after stopping PGE. infusion. It should be kept in mind that Hypertrophic Pyloric stenosis due to PGE infusion can be transient and pyloromyotomy should be kept for patients with persistent findings. However, conservative management with Atropine may be justified especially in cases with cardio-respiratory embarrassment. CONCLUSION Severe intra-abdominal hypertension may result in cardio-respiratory compromise. Progression may be rapid in patients at risk. This may present with features of compressive shock. Diagnosis may be difficult. Immediate relieve of abdominal tension is the treatment. REFERENCES 1. Richards J, Wilcox $. Diagnosis and management of shock in the emergency department. Emerg Med Pr. 2014;16(3):1-2. 2. Malbrain MLNG, Roberts DJ, Sugrue M, De Keulenaer BL, Ivatury R, Pelosi P, et al. The polycompartment syndrome: a concise state- of-the-art review. Anaesthesiol Intensive Ther [Internet]. 2014 [cited 2015 Jan 9};46(5):433-50. Available from: Itp:/ /www.nebinim nih. gov / pubmed /25432560 Malbrain M, Cheatham M, Kirkpatrick A, Sugrue M, Parr M, Waele J De, et al. Results from the International Conference of Experts on Intra-abdominal Hypertension and Abdominal Compartment Syndrome . I Definitions . Intensive Care Med 2006,32(11):1722-32. Morita S, Sakurai K, Watanabe Y, Nishino T. Obstructive Shock Caused by a Giant Hiatus Hernia, Intern Med [Internet]. 2014 [cited 2015 Jan 16];53(23):2755-2755. Available from: hitp:/ /jlejst.go,jp/DN/JSTJSTAGE/ internal medicine/53.3280?lang=enéfrom=CrossRef& type=abstract Huprikar NA , Kurtz MT MC. Massive splenomegaly and lymphopenia?: a unique case of obstructive shock. BMJ Case Rep. 2013,0¢t30. Soyer'T, YalcinS, Bozkaya D, YititS, Tanyel FC. Transient hypertrophic pyloric stenosis due to prostoglandin infusion. j Perinatol [Internet] 2014 Oct [cited 2015 Jan 16];34(10):800-1. Available from hitp:/ / www ncbi.nlm.nih.gov/ pubmed /2526 3728 Ford HR, Pediatric Surgery. In: Brunnicardi CF AD, Billiar TR, Dunn DL, Hunter GPR, editors. Schwartz's Principles of Surgery. eight. Mc Graw-Hill,2007. 374 Nigerian Journal of Medicine, Vol.26 No. 4, Oclober December, 2017, ISSN 1115-2513ournalofmedicine@gmail.com www.nigerianjournalofmedicine.com