Role of Imaging Studies in Evaluating Patients Post Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy

A 77-year-old male presented to the ED with a new onset of acute abdominal pain, nausea, and vomiting. He had a previous surgical history of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) for an appendiceal tumor. Despite the repeated reassuring abdominal examinations, CT abdomen showed high-grade bowel obstruction and perforation. He was urgently taken to the operating room and underwent resection of 70 cm segment of small ischemic bowel with primary anastomosis. His postoperative course was complicated with atrial fibrillation (AF) requiring cardioversion and medical therapy. Later, he was discharged home under stable conditions. Relying on abdominal signs, an abdominal exam in a patient with a previous history of extensive peritonectomy and post-HIPEC surgery is challenging due to the altered peritoneal anatomy. As a result, the abdominal examination findings can be benign and misleading. This can lead to delayed surgical intervention, thereby increasing morbidity and mortality significantly. Therefore, a detailed evaluation with a low threshold for abdominal imaging studies like abdominal X-rays and CT abdomen series is warranted in this subset of patients

Pain Management for Pregnant Women in the Opioid Crisis Era

Acute and chronic pain management during pregnancy, after delivery and even during lactation are challenging even for experienced physicians. This chapter intends to cover pregnancy-induced physiological changes in relation to pain conditions. It also covers the most common pain disorders in pregnancy and provides a comprehensive summary of the pharmacological and non-pharmacological options for pain management in pregnancy. Additionally, pain management in context of opioid abuse will also be covered, as high prevalence of opioid prescription is linked to the very poor maternal and fetal outcomes. The possibility of maternal opioid abuse and fetal opioid withdrawal should be known to all physicians, given its rising trends. Multimodal protocols and opioid sparing strategies are highly essential for safe pain management during pregnancy and have been discussed. This chapter is intended to be a fast and detailed review for residents, pain fellows, and physicians who seek pain control in pregnant women