Volvulus can affect the stomach, small intestine, and parts of the large intestine. Posts. Introducing a naso-gastric tube through the nose into the stomach to pull out air and fluid and allay abdominal swelling. Diagnosis. This practical handbook delivers complete, to-the-point, evidence-based guidance on the preoperative, perioperative, and post-operative medical care of surgical patients. I would contact my GI consultant or GP as a matter of urgency. You will be given food through a nasal tube or intravenously to prevent malnutrition. Intestinal pseudo-obstruction. Kliegman RM, et al. Volvulus is a special form of mechanical intestinal obstruction. It is introduced into the intestine via an endoscope passed through the mouth or colon. Treatment for twisted bowel depends upon the cause and generally calls for hospitalization for a couple of days. https://www.niddk.nih.gov/health-information/digestive-diseases/intestinal-pseudo-obstruction. A volvulus occurs when part of the small or large intestine twists, causing a dangerous blockage. In the absence of necrosis, if the bowel appears to be edematous or congested, simple derotation, with or without fixation of the involved small bowel, may be considered. First, the band was located 20 cm superior to postsurgical adhesions in the lower abdomen and pelvis. Intussusception. There were no masses, ulcers, scarring, or perforations. It happens when contaminated water accumulates in the outer ear, becoming a hot-bed for germs and microbes to thrive under moist, warm conditions. Case report and review of the literature,”, J. Twisted bowel is medically termed intestinal obstruction; it is a blockage / occlusion due to which food and / or liquid cannot pass through the small intestine or large intestine. The clinician must utilize multislice CT with contrast to achieve visualization of the underlying pathology [1]. Smooth muscle fibers in the muscularis propria were split and fragmented, with strands of myocyte cytoplasm floating in extravasated blood (Figure 2(b)). Elsevier; 2020. https://www.clinicalkey.com. A 24-year-old member asked: What does it mean to have a twisted bowel? "There was nothing more the team could have […] He or she will also do a physical exam to assess your situation. A bowel obstruction, also known as a gastrointestinal blockage, is a common canine problem. Severe abdominal pain, cramps and bloating. Some common symptoms include: Vomiting, usually with abdominal contractions. It's most often a normal anatomic variation. Overview. By Emily Fowler. In our case, the fibrous band causing volvulus was located at the mesenteric root of the ischemic segment of jejunum. It typically causes no symptoms and requires no treatment, unlike a twisted colon. This twisting can also cut off the blood flow to the intestine, and the intestine can be damaged. Causes of Growing Pains in Children? demonstrated that multiple transition points, defined as a segment of dilated bowel followed by a segment of collapsed bowel located in the posterior abdomen, are more prevalent in patients with SBV compared to other etiologies of small bowel obstruction [14]. Neuromuscular Therapist Lee Albert shares his Integrated Positional Therapy (IPT) techniques, which were designed to eliminate pain rather than simply hide the symptoms. Understanding an Intestinal Obstruction. Tumors, scar tissue (adhesions), or twisting or narrowing of the intestines can cause a bowel obstruction. A single copy of these materials may be reprinted for noncommercial personal use only. A volvulus is when a loop of intestine twists around itself and the mesentery that supports it, resulting in a bowel obstruction. This may happen over and over again so the vascular supply is not getting as compromised due to the moments the intestines are not twisted. The large intestine is subdivided into the colon, rectum and cecum. The authors declare that there is no conflict of interests regarding the publication of this paper. If you know the causes, you can avoid dangerous situations. Individuals who experience mild, moderate or severe symptoms of a bowel obstruction are generally encouraged to follow a partial bowel obstruction diet that may include a low-residue, minimal-residue or fluid-based diet, respectively. This fully revised edition of Fundamentals of Diagnostic Radiology conveys the essential knowledge needed to understand the clinical application of imaging technologies. Bowel obstruction: A narrative review for all physicians. The . Symptoms include abdominal pain, abdominal bloating, vomiting, constipation, and bloody stool. Dogs are naturally curious, and many have a desire to eat or chew almost anything. © 1998-2021 Mayo Foundation for Medical Education and Research (MFMER). Tests and procedures used to diagnose intestinal obstruction include: Physical exam. Jared Klein, Kathryn Baxstrom, Stephen Donnelly, Patrick Feasel, Paul Koles, "A Fatal Twist: Volvulus of the Small Intestine in a 46-Year-Old Woman", Case Reports in Medicine, vol. 11th ed. Yes: Usually this is a developmental defect in whcih the intestine are not properly attached to the abdominal wall. From age-specific diagnoses and chief complaints through developmental considerations and psychosocial issues, this text guides you through the full range of medical and surgical conditions commonly encountered when treating pediatric ... We present a case of a 46-year-old woman whose clinical evaluation did not lead to surgical intervention, resulting in death due to complications of small bowel infarction. An ultrasound was interpreted as negative; she was discharged home. This content does not have an Arabic version. Malrotation occurs when a problem w. It is uncertain why neither emergency department chose to use this imaging modality, which may have produced a better outcome. The most common symptoms are vomiting bile, stomach pain, diarrhea or constipation, and bloody stools. Sigmoid Volvulus. Advertising revenue supports our not-for-profit mission. Postmortem exam revealed acute hemorrhagic necrosis of a segment of jejunum secondary to volvulus. The subsequent forceful small bowel peristalsis is believed to cause primary SBV [10]. Serious causes of twisted bowel result in intestinal strangulation, and if left untreated can lead to entire segments of the intestinal tract to die off. The symptoms of twisted bowel may vary in respect of its severity, the portion of intestine involved and the age of the patient. Typically, when a patient requires opioid management, further workup is initiated to identify the underlying etiology. While congenital fibrous bands are rare in adults, this interpretation is favored for two reasons. It depends which part of the intestine has been twisted. Emergent surgical intervention is necessary to avoid ischemic necrosis or perforation of the bowel [1, 5]. The band was located 10 cm inferior to the edge of the liver and 4 cm right of midline. Twisted bowel is medically termed intestinal obstruction; it is a blockage / occlusion due to which food and / or liquid cannot pass through the small intestine or large intestine. Delay in treatment can be fatal. Most small-bowel obstructions cause waves of cramping abdominal pain. Though twisted stomach is a very serious disease, it is good to know that it can be treated as long as you are aware of the symptoms and act promptly. Rajan E (expert opinion). These abnormal twists in the intestine can lead to serious complications and can even lead to death. However, after a period they become severe and may require urgent medical attention. If neglected and not treated promptly, the individual can die. The symptoms and signs of twisted bowel differ as per the part of bowel that is affected and the severity levels. Copyright © 2015 Jared Klein et al. 2015, Article ID 391093, 4 pages, 2015. https://doi.org/10.1155/2015/391093, 1Department of Pediatrics, Virginia Commonwealth University Health System, Richmond, VA 23220, USA, 2Department of Internal Medicine, University of Minnesota Medical Center, Minneapolis, MN 55454, USA, 3Departments of Family Medicine and Emergency Medicine, Christiana Care, Wilmington, DE 19899, USA, 4Department of Pathology, Cleveland Clinic, Cleveland, OH 44195, USA, 5Department of Pathology, Wright State University, Dayton, OH 45435, USA. The dog's stomach becomes overstretched, expanding to a far larger size, after which the distended stomach rotates, sometimes by as much as 360 degrees. Guide To Common Bowel Obstruction Symptoms. Numerous tables, graphs, and figures add further clarity to the text." ...Written by experts in the field, this book is updated with the latest advances in pathophysiology and treatment. Bowel obstruction is nothing chronic — there's usually a very dramatic progression of symptoms." Hereof, what is the treatment for a twisted bowel? When your intestine works normally, digested food moves from your stomach to your rectum. This is caused by excessive gas content in the stomach due to the blockage of food, and once twisted, cuts off the blood supply to the stomach and any exit for the trapped gas. In adults, SBV is most often secondary to postsurgical adhesions, fibrous bands involving the mesentery, or congenital malrotation of the small bowel [4]. Likewise, the blood in the stomach also can't circulate. This situation can lead to death of the blood-starved tissue and tearing of the intestinal wall—a life-threatening event and a medical emergency. Get the Free App for Doctors. Often, abdominal pain will precede alterations in laboratory blood work results by hours. Found inside â Page 237Character of Symptoms , cramps , with constipation lasting three weeks ; finally complete obstruction with fecal ... Strangulation , twisting of base of diverticulum ; constriction by twisting of gut at point of origin of diverticulum . It forces open the colon to clear up the occlusion. Small intestinal obstruction, where the path of the small intestines is in some way obstructed, can be caused by the ingestion of foreign bodies, tumors, hernias, intussusception (a condition in which one portion of the small intestine slides into the next, causing blockage), or mesenteric torsion, which is a particular twisting of the . A precipitating factor may be the ingestion of a large amount of fiber after extended periods of fasting during the Ramadan festival [1–3]. All that you need to do in order to be able to save your dog is to be well informed. This book analyses current practices in HPN, with a view to inform best practice, covering epidemiology of HPN in regions including the UK and Europe, USA and Australia, its role in the treatment of clinical conditions including ... What isn't absorbed by the intestines continues along the digestive tract and is expelled as stool during a bowel movement. Despite the efforts of the scientists and medical practitioners, the mortality rates are still high and the incidence of sepsis is increasing. In this book we provide an update on several aspects of sepsis. Symptoms of a bowel obstruction or a small bowel obstruction . The patient was given one liter of normal saline, hydromorphone, promethazine, and ondansetron. Severe infec. In patients with clinical evidence of small intestinal obstruction, the diagnosis of SBV may be suggested by abdominal multislice CT scan that demonstrates the “whirl sign” due to twisting of the small bowel, mesentery, and mesenteric vessels [1, 3, 5–8]. Three weeks ago I injured myself twisting while moving a heavy wheelie bin. She was nauseated and had vomited yellow, nonbloody fluid at home. Does Coke help with bowel obstruction? Her unremitting abdominal pain, persistent vomiting, and absolute neutrophilia were consistent with an acute process. (b) Smooth muscle fibers in the muscularis propria split and fragmented, with strands of myocyte cytoplasm floating in extravasated blood. For this digital book edition, media content is not included. A twisted bowel is caused when the intestines fold over themselves. A. Snyder, C. Lum, and M. D. Davidson, “Elderly patient with small bowel volvulus,”, F. M. Akgür, F. C. Tanyel, N. Büyükpamukçu, and A. Hiçsönmez, “Anomalous congenital bands causing intestinal obstruction in children,”, W. Wiesner, B. Khurana, H. Ji, and P. R. Ros, “CT of acute bowel ischemia,”, P. F. Lawrence, R. M. Bell, and M. T. Dayton, “Small bowel obstruction,” in, P. S. Sandhu, B. N. Joe, F. V. Coakley, A. Qayyum, E. M. Webb, and B. M. Yeh, “Bowel transition points: multiplicity and posterior location at CT are associated with small-bowel volvulus,”, U. Rudloff, “The spoke wheel sign: bowel,”, N. de Korte, C. T. Grutters, and J. P. Snellen, “Small bowel volvulus diagnosed by the CT ‘whirl sign’,”. Ear infection symptoms in adults - Outer Ear (Swimmer's ear) This is also called 'swimmer's ear' because it is seen mostly in swimmers. Dec. 11, 2020. Found inside â Page 841Twisting , or torsion , is not an unfrequent cause of intestinal obstruction , and may involve almost any portion of the ... Indeed , the rotation is rarely sufficiently great to produce complete obstruction , and the symptoms are ... Managing Impulsivity Disorder Naturally with Diet and Vitamins. Risk factors for volvulus include intestinal malrotation, Hirschsprung disease, an enlarged colon, pregnancy, and abdominal adhesions. Infants and small children are relatively more susceptible to volvulus when compared to adults. Twisted intestines may become blocked (obstructed) or may become injured when the twisting . Broadly, the . Article of the Year Award: Outstanding research contributions of 2020, as selected by our Chief Editors. A pseudo obstruction or a paralytic ileus causes similar symptoms of intestinal obstruction, but does not involve a physical obstruction in the bowel. The humorous science writer offers a tour of the human digestive system, explaining why the stomach doesn't digest itself and whether constipation can kill you. The most common causes of intestinal obstruction in adults are: In children, the most common cause of intestinal obstruction is telescoping of the intestine (intussusception). Other possible causes of intestinal obstruction include: Intestinal pseudo-obstruction (paralytic ileus) can cause signs and symptoms of intestinal obstruction, but it doesn't involve a physical blockage. This book is particularly timely given the recent advances in the management of Short Bowel Syndrome, including the availability of pharmacologic agents to enhance intestinal absorption, refinements in parenteral nutrition, and surgical ... Types of surgeries for twisted bowel include: Colectomy: This is a surgery that removes all or part of your . Mayo Clinic facts about coronavirus disease 2019 (COVID-19), Our COVID-19 patient and visitor guidelines, plus trusted health information, Mayo Clinic Health System patient vaccination updates, Mayo Clinic Graduate School of Biomedical Sciences, Mayo Clinic School of Continuous Professional Development, Mayo Clinic School of Graduate Medical Education, Try Mayo Clinic Health Letter - get FREE book. It is a rare condition where the stomach rotates abnormally more than 180º. Posted by Dr. Chris. Mesenteric rotation (torsion) causes vascular insufficiency, and resultant ischemia and tissue hypoxia. In: Sleisenger and Fordtran's Gastrointestinal and Liver Disease: Pathophysiology, Diagnosis, Management. Purina One which they changed recently and I keep saying he started getting sick after he started eating it. Medications will be prescribed which bring about muscle contractions and help move food and fluids through the bowels. Any condition that results in the abnormal gyration or twisting of bowel organs around their own axis can constitute a twisting of the involved bowel organ. INTRODUCTION — In February 2020, the World Health Organization designated the disease COVID-19, which stands for "coronavirus disease 2019," a pandemic. The intestines extract nutrients from the foods. The onset of symptoms may be insidious or sudden. Find fast answers to inform your daily diagnosis and treatment decisions! Ferriâs Clinical Advisor 2021 uses the popular "5 books in 1" format to deliver vast amounts of information in a clinically relevant, user-friendly manner. The necrotic segment showed diffuse thinning of the muscularis propria and transmural dark purple discoloration (Figure 1(c)). Adhesions are the most common cause in adults; congenital fibrous bands are rare and typically cause symptomatic obstruction in children [11]. Depending on the severity of the bowel obstruction, dietary recommendations may vary substantially. The mesentery and necrotic segment were twisted and tethered under a thick band of elastic connective tissue in the posterior upper abdomen (Figure 1(b)). While volvulus is caused by the torsion of the intestine, it is also possible for intestinal detorsion, where the intestines spontaneously unwrap themselves. Symptoms of canine twisted bowel? Twisted gallbladder is a serious life threatening condition which needs immediate surgical intervention. Product. It can also cause compression of nearby blood vessels, thereby choking blood supply to the stomach. Apart from affecting normal movement through the stomach, a gastric volvulus can also cause the blood vessels supplying the stomach to become compressed. Is a twisted bowel painful? Other radiographic signs, such as the “spoke wheel,” “beak,” and “barber pole” signs, have been described in the literature as well [6, 15]. This causes an intestinal blockage. According to Grasso et al., there have not been any prospective, randomized trials comparing outcomes of derotation versus resection with anastomosis. Your treatment plan depends on where the twist is in your intestine and your overall health. CLEARWATER, Fla. (AP) — Florida's most famous dolphin Winter, beloved by fans around the world and star of the movie "Dolphin Tale," died of twisted intestines, according to necropsy results released by the aquarium Saturday. ; 2 Usually caused by ingesting a foreign body, bowel obstructions are also caused by certain medical conditions. In the beginning the symptoms may be mild and the patient may consider it to be normal. The most common symptoms are vomiting bile, stomach pain, diarrhea or constipation, and bloody stools. Most authors agree that resection is required for necrotic bowel [1–5, 9]. SBV is a rare cause of small bowel obstruction in Western countries, comprising 1–6% of cases [1]. However, it accounts for 20-35% of small bowel obstructions in Asia, Africa, and the Middle East. Pain in the abdomen which comes and goes intermittently. The patient was brought to another emergency department seven hours later with continuing abdominal pain that had begun 15 hours earlier. It results from abnormal twisting of a loop of bowel around the axis of its own mesentery [5]. Designed to be a single source of guidance on diagnostic imaging of the abdomen. Twisted bowel signs and symptoms. If . ; 3 Common symptoms of bowel obstruction including vomiting, dehydration, and abdominal pain and swelling. In children the most common type of volvulus occurs in the middle part of the guts, and is usually due to the child having been born with a slightly abnormally placed gut in the first place (malrotation). Published mortality rates vary, but the consensus is 10–35% [1–3, 9]. Twisted bowel in elderly may be more concerning than when it occurs in younger adults. Intestinal obstruction causes a wide range of symptoms, including: severe bloating; abdominal pain; decreased appetite; nausea; vomiting; inability to pass gas or stool Causes of intestinal obstruction may include fibrous bands of tissue (adhesions) in the abdomen that form after surgery; hernias; colon cancer; certain medications; or strictures from an inflamed intestine caused by certain conditions, such as Crohn's disease or . The current article describes this syndrome with respect to its etiology and symptoms. Secondary causes are numerous and include postsurgical adhesions, malrotation, and, as in our case, congenital fibrous bands. Mayo Clinic; 2019. Placing an IV line so that fluids can be administered. (b) Note the band of elastic tissue causing tissue strangulation and necrosis. Abdominal Pain and Cramping Achalasia / Dysphagia Acne or Pimples Allergies - Seasonal Anal Stenosis and Strictures Anal Fissure Anemia Arthritis Attention Deficit Hyperactivity Disorder (ADHD) Back Pain Bladder Infection (UTI or Cystitis) Breast Cancer . Intestinal obstruction is a blockage that keeps food or liquid from passing through your small intestine or large intestine (colon). The doctor may suspect intestinal obstruction if your abdomen is swollen or tender or if there's a lump in your abdomen. When the relative arrived at the patient’s home, the patient was unresponsive with bloody emesis on and around her body. Abdominal pain. Commonly reported symptoms of a twisted . Get the Free App for Members. All rights reserved. A volvulus happens when the intestine becomes twisted. SBV may lead to ischemic necrosis of the bowel, underscoring the necessity of prompt diagnosis and surgical intervention [2, 4, 5, 7]. Guan, and Y. Gao, “Multislice computed tomography angiography findings of chronic small bowel volvulus with jejunal diverticulosis,”, V. M. S. Vega, M. M. de Gracia, A. V. Sánchez, E. A. Gamarra, and G. G. Moll, “Trapped on the ‘whirl’: diagnostic sign on emergency CT,”, E. Grasso and L. Sciolli, “Spontaneus small bowel volvulus in an adult. The mucosa was mostly absent, showing only scattered remnants of villi with hypocellular lamina propria and no intact epithelium. Canine twisted stomach or bloat is a life-threatening condition that can quickly become fatal. Your physician may advise treating the obstruction with a self-expanding metal stent. 24/7 visits - just $39! A right upper quadrant ultrasound was performed and interpreted as negative for gallbladder, common bile duct, or pancreatic pathology. does it mean that your intestines are literally twisted? Small-bowel obstruction. Inflammatory bowel diseases, such as Crohn’s disease. Accessed Dec. 7, 2020. Such a condition is known as strangulation. This age association may be due to acquired redundancy of the . Physical exam showed a soft, nondistended, nontender abdomen with no masses or guarding. The mesentery becomes so tightly twisted that blood supply is cut off, resulting in bowel ischemia. Colon lesions symptoms. Some people refer to a twisted colon as a "Redundant Colon". Diarrhea can be present due to abnormalities in the small intestine or the large intestine. The small intestine is subdivided into the ileum, duodenum and jejunum. Designed as a guide to clinical radiology of the small intestine, the book addresses the pertinent aspects of gastrointestinal radiology, specifically the problems of technique and interpretation that confront the radiologist with interest ... 21st ed. Why Am I Coughing Up Black Mucus After Stopping Smoking? A bowel obstruction can also cause twisting of the intestines, but usually happens "because of a scar-like band" in the intestines that can form after abdominal or pelvic surgery, Dr. Childs says. First, the band was anatomically isolated, located on a significant distance (about 20 cm) from the mild postsurgical fibrous adhesions identified in the lower abdomen and pelvis. SBV may be primary, without any underlying anatomic abnormalities or known predisposing factors. Inserting a catheter in the bladder to drain urine. When this happens, the dog's stomach can adopt unnatural positions, becoming twisted in such a way that its contents can't pass into the intestine or be vomited back up. A sporadic form of strangulating intestinal obstruction,”, J. Ruiz-Tovar, V. Morales, A. Sanjuanbenito, E. Lobo, and E. Martinez-Molina, “Volvulus of the small bowel in adults,”, J.-C. Huang, J.-S. Shin, Y.-T. Huang et al., “Small bowel volvulus among adults,”, P. G. Katis and S. Dias, “Volvulus: a rare twist on small-bowel obstruction,”, S.-T. Feng, T. Chan, C.-H. Sun et al., “Multiphasic MDCT in small bowel volvulus,”, X.-B. (c) Necrotic segment of bowel with transmural necrosis. A volvulus is considered a life-threatening problem. The ASCRS Manual of Colon and Rectal Surgery was designed to provide a rapid access pocket reference for residents, fellows, private clinicians, and allied health professionals caring for patients with colorectal surgical diseases. World Journal of Emergency Surgery. A 46-year-old African-American woman came to the emergency department because of acute lower abdominal pain of four-hours duration. Without treatment, the blocked parts of the intestine can die, leading to serious problems. Generally within 24-48 hours weakness and death follow. The term 'spastic colon' comes from the idea that muscle spasms in the large intestine were to blame for abdominal pain and changes in bowel habits. This is because the intestine can die when it's twisted and doesn't have enough blood supply. Answer (1 of 3): A volvulus refers to abnormal twisting of a part of the large or small intestine. In infants, volvulus of the small intestine often occurs due to malrotation. Spastic colon is another term for irritable bowel syndrome (IBS), a common condition with symptoms including cramping, constipation or diarrhea, bloating, and abdominal pain. Volvulus can be primary, without any predisposing anatomic abnormalities and risk factors, or secondary to congenital or acquired lesions [2]. As stated previously, this is the key imaging modality that may demonstrate the “whirl sign” that can suggest the diagnosis of SBV. The virus that causes COVID-19 is the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Volvulus occurs when the intestine twists around itself and the mesentery that supports it, creating an obstruction. Causes can include: Diseases and conditions that can increase your risk of intestinal obstruction include: Untreated, intestinal obstruction can cause serious, life-threatening complications, including: Mayo Clinic does not endorse companies or products. As an introduction to both the art and science of palliative care, this book reflects the perspectives of one physician who has dedicated his career to this rapidly evolving field. the book links real stories of illness with practical ... Any change in the shape of the intestine is known as twisted intestine or twisted bowel. Intestinal obstruction. Accessed Dec. 10, 2020. (c) Focally, only a thin layer of muscularis propria remains beneath the serosa. Answer: One of the first things that comes to mind regarding "twisted intestines" is likely a volvulus, though not exclusively. Further serious complications include stomach tears. A volvulus causes an obstruction or blockage in the intestine, preventing food from being digested normally. Pain in the abdomen (belly) Causes of Twisting Bowel. Second, the band’s large size is difficult to explain as an acquired lesion, especially without a history of trauma or previous surgery in the epigastric region. Depending on the etiology, intestinal volvulus may present as a closed-loop obstruction in which a segment of bowel is occluded at two points along its length, resulting in fluid sequestration and gas production due to bacterial overgrowth. The etiology of this volvulus was caused by an elastic fibrous band at the root of the jejunal mesentery. This innovative introduction to patient encounters utilizes an evidence-based step-by-step process that teaches students how to evaluate, diagnose, and treat patients based on the clinical complaints they present. This book provides up-to-date evidence on laparoscopic emergency surgery and supplies concrete advice on when and how to approach patients laparoscopically in an emergency setting. It sounds more like slow transit, with the feelings you are describing, but that can only be diagnosed by having a special test. The majority of children with malrotation develop symptoms within the first year of life. Laboratory studies, including AST, ALT, Alkaline phosphatase, lipase, and electrolytes, were within normal limits. 50% off with $15/month membership. Mayo Clinic. Take Control of Your Cancer Risk: A WebMD Essential Guide shares straightforward information and equips you with strategies to help you on a journey to better health, including: assessing your cancer risk knowing which screenings you need, ... Dr. Ronald Kline answered. What Causes A Twisted Gallbladder? A small bowel obstruction commonly occurs where loops of intestine can easily get blocked or twisted. I feed him only the best dog food. The pain is unbearable and you will have no action from your bowels at all. So be sure to contact your veterinarian right away. Acclaimed for its unsurpassed readability and manageable scope, Ashcraftâs Pediatric Surgery presents authoritative, practical guidance on treating the entire range of general surgical and urological problems in infants, children, and ...
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