Physician's Assistant

Meeting Fri 30 May 2025 17:03

Last Modified: 310 days ago

MRN:

Content:

MDT discussion regarding a 33-year-old male patient who presented with vomiting and is currently an inpatient. He has been experiencing symptoms since his laparoscopic cholecystectomy in June last year.

Current symptoms:
- Unable to tolerate solid food
- Tolerates liquids and thick soups only
- Develops symptoms approximately 4 hours after eating solids
- Has lost one stone since admission
- Currently on liquid diet with improvement

Previous investigations:
- CT scan (1 month prior): Unremarkable, post-cholecystectomy changes noted. Initial report by MSK radiologist suggested possible abrupt narrowing and transition in small bowel with some faecalisation, but this was subsequently reviewed and felt to be non-specific
- MR small bowel (27 May): Unremarkable with no free fluid. Poor bowel distension noted. Patient tolerated 1.4 litres of mannitol contrast well with subsequent loose stools
- OGD: Showed duodenitis and oesophagitis (possibly secondary to vomiting)

Past medical history:
- Multiple hospital admissions including episodes in December 2023 (campylobacter, profuse diarrhoea, vomiting, chest pain) and March 2024 (severe epigastric pain, vomiting, loose stools, rigors)
- Previous CT and MRCP showing possible ascending cholangitis
- Multiple leg operations over several years
- Stable transaminitis likely secondary to fatty liver
- Normal inflammatory markers

Discussion points:
- Differential includes adhesional stricture post-cholecystectomy, though distal small bowel obstruction following laparoscopic cholecystectomy would be unusual
- Other considerations include ischaemic stricture, coeliac disease (TTG not yet checked), or AVM-related stricture
- Poor distension on MR small bowel limits diagnostic value

Plan:
1. Check TTG to exclude coeliac disease
2. Proceed with patency capsule study as next investigation (minimal radiation exposure)
3. If patency capsule demonstrates obstruction, this would help localise any stricture
4. Further imaging options to be discussed with Dr Fox (senior colleague) including:
   - CT enterography
   - Fluoroscopic examination
   - Repeat MR small bowel with improved technique
5. Continue inpatient management for nutritional support
6. Surgical review may be required depending on findings

Dr Rob Miller (gastroenterology registrar) to email Dr Miles (g.miles@nhs.net) after discussing patency capsule with Dr Stummelt before proceeding.

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Meeting Fri 30 May 2025 17:03

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