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58 The Ulster Medical Journal
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ragments and the patient was commenced on IV ciprofoxacin.Repeat
fuoroscopy with oral contrast con rmed retained
basket in the CBD ( g 2).
A second ERCP under general anaesthetic was per
ormed.Cholangiogram demonstrated single calculus which wasremoved
along with the retained ragment o basket (see
g 3). The remaining metal ragment was grasped witha urther
Dormia basket and removed ( g 4). The patienthad no complications
post-ERCP and is currently awaitinglaparoscopic
cholecystectomy.
Discussion: Traction wire or basket racture, o ten ollowingstone
impaction, is an unusual complication o ERCP and in the past has
been managed surgically 4. Biliary stentingleads to increased risk
o cholangitis by disrupting sphincter o Oddi unction 5. Retained
metal ragments are likely tosimilarly disrupt sphincter o Oddi
unction with subsequenthigh risk o cholangitis.
Conclusion: We have demonstrated success ul medical
management o basket racture with intravenous antibioticsand
repeat ERCP acilitating endoscopic removal o theretained ragment.
In experienced endoscopic teams thisshould be considered as an
alternative to surgery.
No confict o interest declared.
Nicholas M Kelly* ST1 Gastroenterology trainee
Grant R Caddy, Consultant Gastroenterologist
Department o Gastroenterology, Ulster Hospital, Dundonald,
NorthernIreland.
* 49 Ravenhill Park, Bel ast, BT6 0DG
[email protected]
REFERENCES:
1. Farrell RJ, Mahmud N, Noonan N, Kelleher D, Keeling PW.
Diagnosticand therapeutic ERCP : a large single centres experience.
Ir J Med Sci2001; 170(3): 176-80.
2. Christensen, M, Matzen P, Schulze S, Rosenbergy J.
Complications o ERCP : a prospective study. Gastrointest Endosc
2004; 60(5): 721-31.
3. Chong, VH. Yim, HB, Lim CC. Endoscopic
retrogradecholangiopancreatography in the elderly: outcomes, sa ety
and complications. Singapore Med J 2005; 46(11): 621-6.
4. Heinerman M, Mann R, Boeckl O. An unusual complication in
attempted non-surgical treatment o pancreatic bile duct stones.
Endoscopy1993; 25(3): 248-50.
5. Okamoto T, Fujioka S, Yanagisawa S, Yanaga K, Kakutani H,
TajiriH, et al. Placement o a metallic stent across the main
papilla may
predispose to cholangitis. Gastrointest Endosc 2006; 63(6):
7926.
APPENDICECTOMY COMPLICATED BYADDISONS DISEASE
Editor,
Acute appendicitis is the most common surgical emergency.We
describe a case in which
a young man underwent appendicectomy but had acomplicated
postoperative recovery
requiring admission to ICU.
Case report: A 33 year old male presented with a teen-hour
history o vomiting, diarrhoea, and lower abdominal pain oneweek a
ter a holiday in Portugal. He had no signi cant pastmedical
history. On examination he had a tanned appearance,and was tender
with guarding and rebound in the right iliac
ossa. Rovsings sign was positive. He proceeded to theatrewhere
the operative ndings and subsequent histologycon rmed the diagnosis
o acute appendicitis.
Over the next 24 hours he had persisting pyrexia and
becametachycardic and hypotensive. Examination revealed decreased
chest air entry bilaterally and abdominal distension. C
reactive
protein was increased to 369ug/L, rom 5.0ug/L on
admission.Electrolyte pro le con rmed hyponatraemia. Arterial blood
gas sampling showed a metabolic acidosis. He was thoughtto be
septic. The ollowing morning a CT scan o chest and abdomen showed,
bilateral pleural e usions with collapseat both lung bases. There
was ree fuid in the abdomenwith dilatation o the small bowel
throughout its length. Hewas thought to have a postoperative ileus,
but an atypical
pneumonia was also considered.
He was trans erred to ICU. Over the next 24 hours theabdominal
distention increased and in view o this he returned to theatre. At
laparotomy, an infammatory mass was ound in the caecum and terminal
ileum, causing small bowelobstruction. A limited right
hemicolectomy was done. Hisgeneral postoperative condition remained
poor.
Further discussions with the amily revealed that the patienthad
been o a tanned appearance since he had returned
rom holiday in a hot climate 10 years previous. Thetanned
appearance, hyponatraemia, and polyuria raised the
possibility o adrenal insu ciency and a Synacthen testwas
undertaken. This suggested Addisons disease. Treatmentwith
intravenous hydrocortisone and fudrocortisone lead toan immediate
clinical improvement. He was discharged homewell ve days later.
Discussion: The diagnosis o Addisons disease and thenAddisonian
crisis in a postoperative patient is one whichis raught with di
culty. Virtually all the signs mimicother more common conditions
like post-operative ileusor sepsis. A literature review indicates
that these would seem to be the most widely considered initial
diagnosis 1.It has been calculated that some degree o unsuspected
adrenal insu ciency is present in up to 1 in 1000
surgicaladmissions 2, and surgeons should consider this
conditionwhen a postoperative patient ails to recover as
expected.Abdominal pain as the primary complaint occurs in about10%
although a generalised gastrointestinal upset is muchmore common.
Severe abdominal pain with tendernessmimicking peritonitis is
thought to occur in about 7% o cases 2.
Primary adrenocortical ailure is usually due to anautoimmune
mediated destruction o the adrenal gland whichaccounts or around
90% o cases. Females are a ected twoto three times more requently
than males and there is anassociation with other endocrine de
ciencies such as thyroid disease, premature gonadal ailure (usually
ovarian ailure)and type I diabetes 2.
The patient should be treated in the Intensive Care Unit
with
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standard resuscitation measures o airway control,
respiratorysupport, and cardiovascular monitoring. Normal saline
isgiven intravenously to maintain the circulation,
hydrocortisone100mg is given intravenously 6 hourly and
fudrocortisone isadministered as a single dose o 100g orally daily
3. Patienteducation is the key to preventing urther episodes.
Patientsneed to be ully in ormed about the condition and counselled
with regard to appropriate replacement therapy. It might also
be help ul i the patient could wear a Medicalert bracelet and
carry a written record o their medications.
The authors have no confict o interest.
*Michael J. Mullan, SHO General Surgery.
Julie L Sco eld, Consultant Surgeon.
Pawan K. Rajpal, Consultant Surgeon.
Department o Surgery, Antrim Area Hospital, 45 Bush
Road,Antrim.
Correspondence to Dr. Michael J. Mullan, 233 Alexandra Park
Avenue, Bel ast, BT15 3GB.
[email protected]
REFERENCES
1. Sabharwal P, Fishel RS, Breslow MJ. Adrenal insu ciency
Anunusual cause o shock in postoperative patients. Endocrine
Practice 1998; 4(6): 387-90.
2. Laws S, Cook PR, Rees M. Adrenal insu ciency masquerading as
anacute abdomen. Hospital Medicine 2001; 62: 118-9.
3. Jahan MA, Harrison BJ. Investigation and management o
adrenaldisease. Surgery 2003; 21(12): 305-9.
