Friday, January 28, 2011

CASE: Stab in abdomen with holo visceral injury + Missed pancreatic injury leading to .....

38 yrs male with stab in abdomen before one month...with peritonitis ...explored and found to have Transverse colon and gastric perf. ...closed primarily....improved gradually.....

developed distension and persistant fever....G/C detoriating gradually.....CECT was done....found to have RHC collection ? biliary?
next day Per Cut Drain was kept....draining bile...ERC tried but papilla was not located...

later Referred for biliary fistula to me...

As the fistula was controlled with drain around 200ml of bile/day...and pt was clinically improving and taking oral diet..passing stool....kept conservatively....
Unfortunately pt took DAMA....re admitted after 5days with distension of abdomen and drain out put of >1400ml/day.....? high out put fecal fistula ......and pt started detoriating fast with sepsis and shock...

CECT was repeated ... Revalled multiple intra abdominal collection and peri pancreatic necrosis...




Taken up for surgery.... Intra abdominal collections drained....bowel was healthy though out..
Drain tract explored from rt flank...and RETROPERITONEAL NECROSECTOMY was done thorough lavage and Laparoscopic (retro peritoneal) drainage of dirty material was done...



Remained on venti for 2.5 days ....now taking oral diet ..passing stool...POD 6 (today) out of ICU. ..having biliary fistula in Rt flank drain which is retro peritoneal and controlled one...TLC  normal...sepsis controlled shifted to ward...now one drain out and patient having a low biliary fistula..<30 ml /day only Rt drain... fit for discharge (24.1.11)....pt discharged.....on 27.1.11..(POD 21)
healing necrosectomy site in Rt flank




ADVANTAGE OF RETRO PERITONEAL NECROSECTOMY....

CASE: TRAUMATIC TRANSECTION OF D-J FLEXURE...

18 yr male with blunt trauma head and abdomen
with Normal CECT Brain.
Pneumoperitoneum and bowel perforation on CECT abdomen.

on exploration almost complete transaction of DJ flexure was found....with peritonitits...


after thorough lavage both the ends of transaction were trimmed 1.5 cm and Single layer Extra Mucosal Interrupted anastomosis done....RT placed in D-2.. and A feeding Jejuonostomy was done...with drainage...
Pt is doing well on POD 6..Today.. tolerating sips orally and Jejuonostomy feeding as well...Out of Sepsis...

DISCHARGED TODAY WITH NORMAL DIET..AND HEALTHY WOUND..27.1.11.

Publish Post

Thursday, January 20, 2011

CASE: CDC TYPE 1B

22 yrs female with colicky pain for 2 yrs..
USG s/o CDC
MRI : S/O CDC TYPE 1 B

Underwent CDC excision and RYHJ






Wednesday, January 19, 2011

CASE : BASICS ARE ALWAYS BASICS

A pt with acute abdominal recurrent pain in LHC region, and centeral umbilical region...with episodic vomiting..in last 15 days got admitted with 3 consultants including a surgeon...but not relieved of pain/vomiting...


CECT was even done ....NORMAL...finally I GOT ref. for acute unresolved abdominal pain....


& ...OH ...............................it was b/l inguinal enterocele (reducible)with dragging pain stretch on mesentry. leading to central abdominal pain (stretch on mesentry) and vomiting...DIAGNOSTIC LAP AND B/L HERNIOPLASTY ( LAP ) DONE AND PT RELIEVED OF EVERYTHING.....

WE should never omit inguinal examination for abdomen....

CASE: clinical judgement and Radiology both can miss lead but pathological diagnosis is always confirmatory....

15 yr male pt with vague abdominal pain and low grade fever..low appetite and diarrhoea..
mild abdominal distension, no tenderness free fluid +
pt roaming around..taking oral diet..passing stool...but constant discomfort

USG: S/O Loculated free fluid and matted bowels p/o Koch's
CECT: Similar findings with dilated appendix with Fecolith in appendix..p/o Koch's
ADA : 150 (normal up to 60)


so by this all means Koch's was almost certain....

but the surprising thing was TLC: 22,000...So fluid (turbid) was aspirated and sent for exm. and showed frank pus (fluid count >75,000 and protein > 3.5: s/o exudate and pus)TLC Elevated to 29,000 (still pt walking, no fever, passing stool, no vomiting) but decision of exploration was taken with consensus of GI Physician, Physician, And Me. and what we found.....1.5 liter of pus with 1 kidney tray full of pus flakes....

sometimes even clinical judgement and Radiology both can miss lead but pathological diagnosis is always confirmatory....(fluid examination, TLC)...and can save lives....

Monday, January 17, 2011

Crohns-disease

http://www.crohns-disease-and-stress.com/

http://www.mayoclinic.org/crohns/

Aliment Pharmacol Ther. 2006 Oct;24 Suppl 3:29-32.

Review article: recurrence of Crohn's disease after surgery - the need for treatment of new lesions.




Tunis Med. 2006 Oct;84(10):595-8.

[Postoperative recurrence in Crohn's disease. Risk factors and methods of prevention]

Thursday, January 13, 2011

CASE: Chronic Ileo-ileo-colic intussusception...

50 yrs female with chronic abdominal pain and features of SAIO
CECT S/O : Ileo-ileo-colic intussusception...With a lead point in ileum...? GIST ? LIPOMA



1 feet of terminal ileum resected and s-s anastomosis done








Wednesday, January 12, 2011

CASE: MASSIVE LOWER GI BLEEDING..With multiple Ileal ulcers...? Enteric ? Aspirin induced

55 yrs female with massive lower GI bleeding...with Hb 4.5 after 6 blood transfusions..
UGIE: was noraml..
LGIE: s/o few non bleeding ulcers in cecum...but ileum full of blood...

was kept conservatively and went into shock with NOR -ADR on 5 ml / hr..and 10 more transfusion was given ... and taken for mesantirc angio- which was inconclusive ---- I got a call.... decision of surgery was taken immediately and  Pt was explored....
and found to have hundreds of ileal ulcers in terminal 2 feets of ileum ....Intra of enteroscopy was done (by gastro physician, which helped us in defining proximal margin  free of ulcers)


 and along with ileal resection Rt hemicolectomy as done with I-T anastomosis....finally pt is walking today...passing normal stool...POD 5.

Sunday, January 9, 2011

CASE: Lower CBD stricture with multiple stones and Multiple Gall Stones..and Sigmoid MPD

65 yrs female with Obstructive jaundice...
USG s/o GSD + CBDS and lower CBD stricture...? CDC 1.
MRI / SVE  S/O lower CBD benign stricture and multiple stones...and Sigmoid MPD.(a congenital anomaly)
ERC failed...stenting done...



CEA / CA 19.9....and Brush Cytology was negative...

CDD-Choledecho Duodenostomy and Cholecystectomy was done...


completed CDD single layer interrupted vicryl

Thursday, January 6, 2011

CASE: SMV THROMBO EMBOLISM AND BOWEL GANGREEN...

35 YRS male with severe agonizing pain in abdomen...
Past history: Operated for buccal malignancy few months ago..SOHND...on Chemotherapy and Radio Rx...On steriod...
CECT: S/O SMV thrombosis and gangrenous small bowel with air in wall of small bowel...
Pre Operatively on Inotrops and septic shock...

Anesthesia: Nasally intubated with bronchoscopy in view of inability to open mouth and SMF.
Explored: Total necrosis of whole jejunum...with peritonitis...
Surgery: Whole jejunum resected and Ileum anastomosed to DJ flexure..lavage and drainage...
post op remained on Venti for 4 days later converted to Tracheostomy...Gradually improved and came out of sepsis...supports weaned off....now taking oral diet and Ambulant.....Repeat CECT...revalled no leak and healthy bowel....on the line of discharge....


Wednesday, January 5, 2011

Isolated Pancreatic Tuberculosis

JOP. J Pancreas (Online) 2006; 7(2):205-210.
University of Pittsburgh School of Medicine. Pittsburgh, PA, USA
CASE REPORT
Context:  Pancreatic tuberculosis is an extremely rare clinical entity, despite the high prevalence of tuberculosis worldwide. The pancreas is protected from direct environmental exposure; therefore most cases of pancreatic tuberculosis arise from contiguous infection from peri-pancreatic lymph nodes or rarely from hematogenous
spread. Pancreatic tuberculosis can present as a cystic or solid pancreatic mass mimicking pancreatic malignancy. Diagnosing pancreatic tuberculosis is a clinical challenge and most cases are diagnosed after surgical exploration for presumed pancreatic cancer. Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is being used more frequently for imaging and sampling of pancreatic lesions. Immediate cytopathologic examination of tissue sampled by EUS increases the diagnostic yield and is standard in many
institutions.

Isolated Pancreatic Tuberculosis
KUWAIT MEDICAL JOURNAL
Kuwait Medical Journal 2004, 36 (4):290-292
CASE REPORT
Tuberculosis of the pancreas is a clinical rarity and mimics pancreatic carcinoma both clinically and
radiologically. A 3 2 - y e a r-old Somali male patient presented with history of vague abdominal pain, weight loss, anorexia and jaundice. Radiological imaging showed gall stones, dilated common bile duct (CBD) and a hetrogenous pancreatic mass. Endoscopic retrograde cholangio pancreatography (ERCP) showed marked narrowing of the CBD with an impression of external compression. Cholecystectomy and  holedochoduodenostomy (CDD) were performed after frozen section histopathology revealed the mass to be tuberculosis. P reoperative diagnosis of pancreatic tuberculos is requires a high index of suspicion and usually its diagnosis is established after surgical tre a t m e n t . T h e response to antituberculosis treatment is very effective.


CASE: ? PRIMARY TUBERCULOSIS OF PANCREAS AND PERI PANCREATIC NODES....

13 Yrs child with h/o pain in epigastric region for last 5 yrs..with back radiation. . . associated with nausea...anorexia....failure to thrive...
was ultimately recently diagnosed as chronic pancreatitis...with dilated duct...and bulky head....
ERCP tried but cannulation was failed....

Referred for surgical management....rest of the work up was completed and diagnosis of TROPICAL VARIETY OF CHRONIC  PANCREATITIS was made..

CECT:


MRI:


SURGERY: LATERAL PANCREATICO JEJUNOSTOMY
FINDINGS: Were Caseating node over head of pancreas...near gastro colic vein...and peri pancreatic few nodes with caseation milking out cheesy material...
MPD was 10 mm and full of cheesy pus......




drained and LPJ done....