Presumably, some of these stones pass spontaneously through the gastrointestinal tract while other larger stones become impacted in the ileum and cause a small bowel obstruction (gallstone ileus). Rarely, large stones become impacted in the duodenum and result in gastric outlet obstruction (Bouveret’s syndrome). In this setting, typical symptoms include upper abdominal pain and recurrent vomiting. Upper gastrointestinal endoscopy reveals a filling-defect within the duodenum but this is not always recognized as a gallstone. The differential diagnosis can include bezoars, foreign bodies and duodenal polyps. If the diagnosis is overlooked at endoscopy, barium studies or CT scans are

usually diagnostic. Most of these patients have been treated by open or laparoscopic surgery (including cholecystectomy) selleckchem but endoscopic extraction of stones has been reported, usually after mechanical or laser

lithotripsy. In Bouveret’s syndrome, gallstones impacted in the duodenal cap are often > 4–5 cm in diameter. Contributed by “
“Any pregnant woman who becomes unwell during any stage of pregnancy following the clinical history should be examined for evidence of liver disease, particularly checks for evidence of liver failure. Physical examination should include evaluations of hydration status, mental status, and search for skin manifestations of liver disease, for example bruising, spider nevi (palmarerythemia may be present in all pregnant women). Even if there are no findings, all should have liver biochemistry and liver function evaluated in addition to hematologic and renal function Doxorubicin datasheet testing. A full medical and surgical history is needed and the specific trimester elucidated. The history (including trimester) and physical examination, taking into account the results of screening blood tests, is required to narrow down the differential diagnosis. If there are any signs of liver failure, transfer to an intensive care unit is preferable. Diagnostic tests for all types of viral hepatitis should be sent, including a vaginal swab for herpes simplex. Ultrasound

selleck compound may contribute towards the diagnosis of fatty liver and Budd–Chiarisyndrome. Close monitoring of the complete blood count and INR are required in those with “presumed” pregnancy-associated toxemia. Curiously, during pregnancy cholestasis although associated with pruritus has a liver biochemical pattern more in keeping with a “hepatitis”; serum bile acid levels clinch the diagnosis. Intense pruritus due to cholestasis of any cause may be very difficult to control with standard oral therapies and may require plasmapheresis. All patients with signs of liver failure should be assessed by a liver transplant service. “
“A man, aged 42, was investigated because of a gradual increase in dyspnea with exercise. His past history included a car accident 18 years previously that resulted in trauma to his abdomen and chest.