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Inserting an NG Tube (Not an NC Tube)!
On occasion (but not routinely) trauma patients need to have their stomach decompressed. The reflex maneuver is to insert a nasogastric (NG) tube. However, this may be a dangerous procedure in some patients.
Some patients may be at risk for a cribriform plate fracture, and blindly passing a tube into their nose may result in a nasocerebral (NC) tube (see picture). This is a neurosurgical catastrophe, and the outcome is uniformly dismal. It generally requires craniectomy to remove the tube.
The following patients are at risk:
- Evidence of midface trauma (eyebrows to zygoma)
- Evidence of basilar skull fracture (raccoon eyes, Battle’s sign, fluids leaking from ears or nose)
- Coma (GCS<8)
If you really need the tube, what can you do? If the patient is comatose, it’s easy: just insert an orogastric (OG) tube. However, that is not an option in awake patients; they will continuously gag on the tube. In that case, lubricate a curved nasal trumpet and gently insert it into the nose. The curve will safely move it past the cribriform plate area. Then lubricate a smaller gastric tube and pass it through the trumpet.
Surgical removal of the gallbladder is one of the most common operations performed by the NHS. More than 60,000 gallbladder removals are performed each year.
Laparoscopic (keyhole) surgery:
Three to four small cuts (each about 1cm or less) are made in your abdomen. One cut will be by the belly button and the others will be on the right side of your abdomen.
Your abdomen is inflated using carbon dioxide gas. This is harmless and makes it easier for your surgeon to see your internal organs.
A laparoscope (a long thin telescope with a tiny light and video camera at the end) is inserted through one of the cuts in your abdomen. This allows your surgeon to view the operation on a video monitor.
Using special surgical instruments, your surgeon will then remove your gallbladder.
Sometimes, if there is a risk of gallstones in the bile duct, an X-ray of the bile duct (operative cholangiogram) will be taken during the operation.
If gallstones are found, they can sometimes be removed during keyhole surgery. If complications occur, your surgeon may have to convert to open surgery.
Bile duct stones can also be removed after your operation with a special endoscopy called an ERCP, or endoscopic retrograde cholangiopancreatography.
After the gallbladder has been removed, the gas in your abdomen will escape through the laparoscope. The cuts in your skin are closed with dissolvable stitches and covered with dressings.
The operation takes 60 to 90 minutes and is usually carried out as a day case, so you can go home that day.
In some circumstances, a laparoscopic cholecystectomy may not be recommended. This may be due to technical reasons or safety concerns.
Your surgeon will be able to discuss with you the reasons why an open cholecystectomy may be recommended in your case.
During an open cholecystectomy a large incision is made in your abdomen and your gallbladder is removed through it.
The incision is around 10-15cm (4-6 inches) long and is made underneath the ribs. This will result in some scarring.
If complications arise during keyhole surgery, such as bleeding, it may be necessary to convert to open surgery. There is around a 1 in 50 chance of this occurring.
Open surgery is just as effective as laparoscopic surgery, but it does have a longer recovery time. Most people take about six weeks to recover from the effects of an open cholecystectomy.
This picture shows the anatomic distribution of Crohn’s Disease.
Normally, the immune system helps protect the body, but with Crohn’s disease the immune system can’t tell the difference between normal body tissue and foreign substances. The result is an overactive immune response that leads to chronic inflammation. This is called an autoimmune disorder.
People with Crohn’s disease have ongoing (chronic) inflammation of the gastrointestinal tract. Crohn’s disease may occur in any area of the digestive tract. There can be healthy patches of tissue between diseased areas. The inflammation causes the intestinal wall to become thick.
There are different types of Crohn’s disease, depending on the part of the gastrointestinal tract that is affected. Crohn’s disease may involve the small intestine, the large intestine, the rectum, or the mouth.
Rebound tenderness is a clinical sign that a health care provider may detect in physical examination of a patient’s abdomen. It refers to pain upon removal of pressure rather than application of pressure to the abdomen. It represents peritoneal inflammation [aggravation of the parietal layer of peritoneum by stretching or moving.]