Introduction
In this paper, the pathopyiology of syncope is discussed with emphasis on Mr. Peter’s medical history and factors that could have contributed to his syncope. Further, the paper discusses the colonoscopy and its findings, his right hemi colectomy and the complications arising from his fall.
Pathopysiology of Syncope
Syncope is the transient loss of memory that occurs when cerebral blood flow falls to below half the normal value resulting in a brief period of inadequate oxygen, glucose and other nutrients supply to the brain tissues (Hainsworth, 2004). Syncope occurs rapidly, lasts for a short duration and the patient almost always recovers spontaneously. Syncope differs from epileptic seizures, cerebro-vascular accidents and concussions which are also characterized by short term loss of consciousness that is not related to low blood flow rates in the brain. In addition, syncope differs from coma which is persisted loss of consciousness. Syncope episodes can be cardiogenic, reflex or orthostatic hypotension and commonly occurs in teenagers and in geriatric patients. Cardiogenic syncope episodes are common in geriatric patients and can result from arrhythmic, obstructive, ischemic and cardiomyopathic disorders (Kenny, 2003). Cardiogenic syncope can produce morbidity and in severe cases death. Reflex syncope results from reflex actions which may lower blood supply to the brains. For instance, teenagers with phobias often experience a syncope event when confronted with this phobia. Reflex syncope may also result from embarrassing situations.
At 74 years of age, Mr. Peter is a geriatric patient and is at risk of suffering from cardiogenic syncope episodes. Certain factors can be identified from Mr. Peter’s medical history that put him at increased risk of experiencing syncope episodes. To start with, Mr. Peters has a history of heart problems. He has a history of angina, stoke, and coronary artery disease. Angina pectoris is a disease that results from local ischemia to the heart muscle. Ischemia describes a condition of restricted blood flow. Mr. Peter’s ischemia can be related to his coronary artery disease which causes spasms and obstruction in the coronary artery leading to restricted blood flow to the heart muscle. Angina pectoris is characterized by severe chest pain. Severe cases of angina can cause a heart attack. On a smaller scale, angina leads to reduced heart performance leading to low blood pressure. Reduced blood pressure limits blood flow to the brain and denies brain tissues of oxygen, glucose and other nutrients thereby causing syncope.
A classic syncope episode has promodal symptoms such as nausea, headache, diaphoresis, dizziness, chest pains, dypsenea, palpitations and paresthesia which occur a few seconds before the synope event (Nair, Padder, & Kantharia, 2003). The management of syncope aims at increasing blood flow to the brain. Since plasma volume is an important factor in influencing the delivery of oxygen and nutrients to the brains, increasing blood plasma levels alleviates syncope. Increasing blood plasma levels can be done through salt loading. Hainsworth cite that exercise training and sleeping with the bead head raised can offer clinical benefits to syncope patients (2004). In addition, diseases such as anemia and severe hemorrhage which affect the blood should be treated to preempt syncope episodes. In the older patients such as Mr. Peter, controlling syncope is important since it has the potential of reducing incidences of other hazardous factors such as falls and conditions involving cognitive impairment and dementia. For Mr. Peters, this has significant implications to the quality of life he will enjoy since he already has Parkinson’s disease and mild dementia hence frequent syncope episodes will increase disease progression.
Colonoscopy
After Mr. Peters was admitted to the hospital due to syncope episodes, he developed abdominal pain. A colonoscopy was conducted to examine the large intestines and the distal part of the small intestines. During a colonoscopy, a digital camera with a flexible fiber optic cable is passed through the anus and used for the examination. This procedure is used for visual diagnosis of ulceration, polyps, colon cancer and inflammatory bowel disease. For persons over 50 years of age, a colonoscopy is recommended every five years to increase the chances of detecting colon cancer and polyps that may turn cancerous early enough to enable treatment and cure (Kaminiski et al., 2010). To perform a colonoscopy effectively, the colon must not have solid matter hence the patient is required to be on a clear liquid diet for two to three days before the procedure is done. A colonoscopy is a relatively safe medical procedure with few risks. However, one of the significant risks associated with a colonoscopy is the risk of splenic rupture which although rare is almost always fatal (Murariu, Takekawa & Furumoto, 2010). Mr. Peter’s colonoscopy revealed a colonic mass which was causing his abdominal pain and constipation. To address this, a right side hemi colectomy was conducted.
The right side hemi Colectomy
A colectomy is any surgical procure that involves the removal of part to the large intestine. A colectomy can be conducted because of colon cancer, inflammatory bowel disease, bowel infraction, typhlitis or diventicular disease of the large intestine. A right side hemi colectomy involves the surgical removal of the ascending part of the large intestine. During the operation, the right side of the colon is removes and the small intestine is attached to the remaining part of the colon. The intestines have a large network of veins, arteries and lymph nodes that must be removed during the colectomy. Traditionally, a colectomy is performed by accessing the colon through an inquisition made in the abdomen (Champagne at al., 2011). Developments in surgical technology have made it possibly to perform minimally invasive laparoscopies to conduct colectomy surgery.
A colectomy operation is associated with various risks. Bleeding is not a significant problem but proper care should be taken to prevent it and provision for blood transfusion in case of hemorrhage. Infections on the wound can occur as part of hospital acquired infection but is easily treated with antibiotics. The most serious problem is leakage in the joint between the large and small intestines that is created by the surgeon. This leads to contamination of the peritoneal cavity, peritonitis and sepsis with death occurring if no interventions are taken to control the leakage (Urban & Lars, 2013). Despite this risks, Sohn et al., asserts that a colectomy with ilectorectal anastomosis is an effective procedure with acceptable mobidity for use in the treatment of bowel disorders including slow transit constipation (2011).
Pre-operation and post operation care is vital in minimizing the risks associated with associated with a colectomy. Pre operation care includes removing solid matter from the bowel and conducting comprehensive assessment of the heart and lungs to ensure that the patient does not have serious medical conditions. In addition, the patient should be kept hydrated with a proper electrolyte balance and injections to reduce the risk of thrombosis. Post operation care focuses on getting the patient back to normal functioning after the surgery. Hygiene is the key concern to prevent wound infection. In addition, the patient may be provided with a catheter to empty the urinary bladder for a few days after the surgery. Intravenous drips and fluid intake are recommended to maintain hydration in the body before the patient can revert back to normal food. If there is leakage at the joint, an abdominal cavity drain is used to remove the leaked substances and minimize the risk of sepsis. After discharge from hospital, patients are encouraged to keep mobile and to refrain from strenuous physical activities and heavy lifting.
Hemoperitoneum
After the fall, Mr. Peter suffered from hemoperitoneum. This refers to the leakage of blood into the peritoneal cavity. Hemoperitoneum can result from blunt and penetrating trauma, rupture of blood vessels in the abdominal cavity, ruptured uterine, corpus luteum and ectopic pregnancy, perforation of the colon and bleeding gastric ulcers. For Mr. Peter, the most likely cause of his hemoperitoneum was ruptured colon because the artificial joint between the small and large intestine made by the surgeon during the colectomy was not yet stable enough to withstand trauma. Diagnosis of the cause of hemoperitoneum is the first step towards managing and controlling this condition. The four main examinations used in diagnosing hemoperitoneum are; exploratory laporatomy, computed tomography, Focused Assesment with Sonography for Trauma (FAST) and diagnostic peritoneal lavage. For Mr. Peter, an exploratory laporatomy was used. During an exploratory laporatomy, an incision is made in the abdominal wall to allow access to the abdominal cavity after which the different organs in the abdominal cavity such as liver, spleen, kidneys, intestines, urinary bladder, female reproductive organs and blood vessels are examined for rupture. An exploratory laporatomy is a standalone surgical procedure but has the advantage of enabling repair of the damaged part when rapture is identified.
Hemoperitoneum can lead to rapid loss of blood and can induce hemorrhagic shock. Massive blood loss reduces blood pressure and leads to failure of some organs including the lungs. This can explain the respiratory failure Mr. Peter experienced. The fluids and blood that had accumulated in the abdominal cavity was drained and the ruptured area was repaired to prevent further blood loss. When left untreated, hemorrhagic shock can cause death. It is therefore important to act on it quickly. Patients receive blood transfusion to make up for lost blood and bleeding is controlled through clamping and ligation of blood vessels.
After the surgical intervention to stop the hemoperitoneum, Mr. Peter recuperated in the ICU and was later transferred to the general ward. He is doing well and is tolerating the liquid diet well. In addition, he is not in pain and he has bowel movement and is passing gas. After full recovery and when he gains the ability to take solid foods, Mr. Peter will be discharged to a specialized nursing facility to provide care for him due to his Parkinson’s disease and dementia. To be holistic and to promote health, the offered care will be focused on preventing falls that can complicate health and alleviating the symptoms of his chronic disease.
Conclusion
Geriatric patients often develop multiple morbidities due to exposure to risk factors or one condition being a risk factor for other conditions. For instance, Mr. Peter was admitted due to syncope episodes. In hospital, he developed abdominal pain and a colonoscopy reveled that he had a colonic mass. This was removed surgically through a right hemi colectomy surgery and just as he was about to be discharge, Mr. Peter suffered a fall. The trauma from the fall caused him to develop hemoperitoneum and the resulting hemorrhagic shock led to respiratory failure. Hemoperitoneum was diagnosed through an exploratory laporatomy and the abdominal cavity was drained. Mr. Peter recovered in the ICU and has been transferred to the general ward.
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