Louisiana Research Day Program Book 2025

Case Studies: Section 1

Case Studies: Section 1

Tristan Moseley, OMS-III 1 ; Walter Sartor, MD 2 1 VCOM-Louisiana; 2 Department of Surgery, St Francis Medical Center, Monroe, LA 94 FUNDOPLICATION REVISION OF A RECURRENT LARGE PARA-ESOPHAGEAL HIATAL HERNIA IN A 63-YEAR-OLD FEMALE

Tiffani Najadifar, OMS-III; Wasifuddin Syed, OMS-III 1 VCOM-Louisiana; 2 Department of Internal Medicine, Willis-Knighton Medical Center, Shreveport, LA 95 ANTIPSYCHOTICS AND ISCHEMIC COLITIS: EXPANDING THE DIFFERENTIAL DIAGNOSIS

Context/Impact: A Hiatal hernia is a condition that occurs when a portion of the stomach protrudes superiorly through the diaphragmatic hiatus into the thoracic cavity. Disruption of this gastroesophageal junction (GEJ) can lead to reflux disease. Type II Para-esophageal hiatal hernias present with significant clinical challenges due to their life-threatening potential for incarceration and strangulation. Report of Case: We report a case of a 63-year old Caucasian female with a history of a para esophageal hiatal hernia, initially diagnosed after a gastric incarceration event in 2014. The gastric volvulus improved with endoscopic intervention. The patient then underwent laparoscopic hiatal hernia repair, and a partial fundoplication was performed to restore the GE junction. Her reflux symptoms were managed with proton pump inhibitors, regular EGDs, and esophageal dilations. Ten years later after experiencing severe nausea and retching status post hip fracture repair, the patients reflux and dysphagia acutely worsened. CT imaging confirmed recurrence of the large para-esophageal hernia containing the upper portion of the stomach. The patient underwent robotic assisted partial

fundoplication revision to address the recurrent hernia. Intraoperatively, the hernia sac was found to be grossly adhered to the left parietal pleura and extensive scarring in the mediastinum was observed. She tolerated the surgery well but required a chest tube due to a pneumothorax that developed upon dissection of the extensive scarring. Her postoperative course was otherwise uneventful, with successful resolution of the pneumothorax and removal of the chest tube. She was able to resume oral intake and was deemed suitable for discharge. On her two week follow-up, she reported to be doing well and tolerating soft foods. She was able to belch and have bowel movements. She reported no reflux, nausea, dysphagia, shortness of breath, or chest pain. The patient was no longer reliant on proton pump inhibitors for reflux control. Comments/Conclusion: This case illustrates the challenges of managing recurrent para esophageal hiatal hernias in the context of prior surgical interventions and additional postoperative complications. Recurrent hernias can lead to significant morbidity and require careful surgical planning. Currently there are some controversies regarding the surgical

management of recurrent para-esophageal hiatal hernias. The main topics up for debate are the effectiveness crural mesh reinforcement during fundoplication, and Roux-en-Y gastric bypass (RYGB) conversion in obese patients, and revisional fundoplication for recurrent hiatal hernias. The recurrence rate for hiatal hernias after fundoplication repair is 25-42%. Redo robotic partial fundoplication was successful in this case, highlighting its potential benefits in managing complex hernias. Continued monitoring, timely follow-up, and individualized treatment plans are crucial for optimizing patient outcomes. The resolution of symptoms in our patient post-operatively underscores the importance of timely and effective intervention.

Context/Impact: This case highlights IC as a rare but serious adverse effect of atypical antipsychotics, particularly those with anticholinergic properties like olanzapine. IC pathophysiology involves transient hypoperfusion to the watershed regions of the colon, such as the splenic flexure and rectosigmoid junction. Anticholinergic agents exacerbate hypoperfusion by reducing gastrointestinal (GI) motility and causing vasoconstriction, which leads to progressive fecal accumulation. This increases intraluminal pressure, compromising intestinal perfusion and causing ischemia. Patients aged 60 years and older with pre-existing vascular conditions, such as atherosclerosis, are at an increased risk for ischemic injury. However, this case is notable because the patient is younger than the typical demographic and does not have significant vascular disease. Despite this, younger patients on antipsychotic therapy can also develop severe IC. The temporal link between olanzapine initiation and symptom onset suggests medication-induced IC may be under-recognized. Failing to recognize this association can delay diagnosis and lead to gangrenous ischemia, increasing

morbidity and mortality. This underscores the critical need for thorough medication history reviews in IC patients, especially those on antipsychotics or other anticholinergic drugs, regardless of age or vascular history. Case: A 40-year-old African American female with hypertension, seizure disorder, and a prior cerebrovascular accident presented to the emergency department with nausea, vomiting, and diarrhea. During admission, she developed hematochezia. Her medications included olanzapine at bedtime, initiated four months prior, along with antihypertensives and antiseizure medications. An abdominal CT scan showed moderate mural thickening throughout the colon, initially suggesting inflammatory bowel disease. A CT angiogram revealed patent superior and inferior mesenteric arteries but focal stenosis at the celiac trunk. A colonoscopy identified severe ischemic colitis (IC) with black eschar from the distal sigmoid colon to the splenic flexure. Biopsies confirmed IC with ulceration and necrosis. The recent initiation of olanzapine, a medication with anticholinergic properties, likely contributed to decreased colonic

perfusion, explaining her symptoms. The patient was mana.

Comments/Conclusion: IC is a rare but serious complication of atypical antipsychotics like olanzapine. Medication-induced hypoperfusion combined with vascular pathology can predispose younger patients to severe ischemic injury. Clinicians should suspect drug-induced IC in patients with GI symptoms and recent antipsychotic use. Early recognition, medication discontinuation, and timely intervention are essential to prevent progression to gangrenous ischemia and reduce morbidity. Detailed medication histories and imaging are key to improving patient outcomes.

108

109 2025 Research Recognition Day