Showing posts with label Cases. Show all posts
Showing posts with label Cases. Show all posts

Case History

A 22 year old female presented with complaints of abdominal pain, abdominal distension, nausea, vomiting and anorexia. On examination the abdomen was distended with diffuse tenderness. But there was no guarding, rigidity or rebound tenderness.

Abdomino-pelvic CT scan was suggestive of Intestinal obstruction and Abdominal Tuberculosis. It revealed  distended bowel loops, large amounts of ascites, symmetrical thickening of the peritoneum and mesentery, nodular thickening of greater omentum and mesenteric lymphadenopathy.

After conservative management for first 24 hours, patient showed no signs of improvement. An exploratory laparotomy was planned. Intraoperatively it was found that Multiple Adhesions between bowel loops and an omental band were causing the obstruction. Adhesiolysis was done and thorough wash was given. Omentum, peritoneum, bowel wall, uterus and adnexa were all seen studded with tubercles. Omentum was thickened and nodular, a piece of it was taken and sent for HPE. Ascitic fluid was blood stained and a sample was taken for biochemical analysis.

Postoperatively patient's condition improved and she passed flatus on 3rd POD and passed stools on 5th POD.  Patient was started on antitubercular drugs and was discharged on 8th POD.


Abdominal tuberculosis showing thickened bowel loops studded with tubercles

Abdominal tuberculosis showing thickened bowel loops  studded with tubercles

Tuberculous peritonitis: Important Points to remember 


Peritoneal tuberculosis is the sixth most common site of extrapulmonary tuberculosis. The top five are lymphatic, genitourinary, bone and joint, miliary, and meningeal. 

Only 17% of cases of peritoneal tuberculosis are associated with active pulmonary disease.  

Abdominal swelling caused by ascites formation is the most common symptom, occurring in more than 80% of cases. 

A positive tuberculin skin test response is present in most cases. But only approximately 50% of these patients will have an abnormal chest radiograph.

Abdominal imaging with ultrasound or CT may suggest the diagnosis but lacks the sensitivity and specificity to be diagnostic.

Ascitic fluid adenosine deaminase activity, in particular, appears to be highly sensitive and specific for tuberculous peritonitis.

The ascitic fluid SAAG is less than 1.1 g/dL, indicating high protein concentration in the ascitic fluid

Microscopic examination of ascitic fluid for acid-fast bacilli identifies the organism in less than 3% of cases, and culture results are positive in less than 20% of cases.


Reference

Case History

A 2 year old male child presented with this moist and pink tissue popping out of the umbilicus.  Patient complained of  minimal amounts of drainage and irritation of the surrounding skin. This swelling started appearing from 3rd month. It was initially small but started growing in size gradually. Patient was initially advised topical application of silver nitrate but it did not resolve with conservative management. It was surgically excised.

Case of Umbilical Pyogenic Granuloma


Umbilical Granuloma

The umbilical cord normally separates within 3 days to 2 months postpartum; after separation, an excess of granulation tissue may persist at the base of the umbilical stump, which may aggregate and persist, for sometimes, to form an umbilical granuloma (UG). Umbilical granuloma is the most common umbilical problem in neonates and young infants.

Differential Diagnosis of Umbilical Granuloma

  • Patent urachus
  • Omphalomesenteric duct
  • Umbilical polyps 
  • Neoplastic swellings 

Management Options

  • Chemical cauterization with silver nitrate or copper sulphate.
  • Topical application of common salt / 82% ethanol or Clobetasolpropionte.
  • Electric cauterization.
  • Cryocauterization.
  • Surgical excision.

References:

http://pedemmorsels.com/umbilical-granuloma/

https://link.springer.com/chapter/10.1007%2F978-3-319-62383-2_27

https://www.jemds.com/latest-articles.php?at_id=6697

https://emedicine.medscape.com/article/935618-treatment
 Progressive Facial Hemiatrophy (Parry-Romberg syndrome)


 Progressive Facial Hemiatrophy (Parry-Romberg syndrome)






This is a patient of Parry-Romberg syndrome, also known as progressive facial hemiatrophy.

It usually starts in childhood and gets worse with time, and it seems to be more common in girls.

It is characterized by slow and progressive hemifacial atrophy of skin, subcutaneous tissue, muscle, and bone.

Congenital mechanisms, disturbance of fat metabolism and trophic malformation of the cervical sympathetic trunk have been implicated.

In addition to the distinctive atrophy that occurs on one side of a patient's face, it can also cause seizures and other neurological problems.

 Progressive Facial Hemiatrophy (Parry-Romberg syndrome)



Reference

https://jamanetwork.com/journals/jamaneurology/fullarticle/1107860
A 28 year old patient, a chronic alcoholic came with complaints of severe abdomen pain of 5 days duration and recurrent vomiting. An erect Xray of Abdomen showed Air under diaphragm. He gave a history of binge drinking 7 days back, which made us suspect a Gastric/ Duodenal Perforation. A separate history of fever or malaise before onset of abdominal pain was unclear.

Laparotomy was performed by midline incision. On inspecting, we found two perforations in ileum about 15 cm apart, the distal one was about 30 cm from ileocaecal junction. The approximate diameter of proximal perforation was 0.5 cm and the distal perforation was 2 cm. Both the perforations were on the antimesenteric aspect of ileum. 

The abdominal contamination was moderate and there were pus flakes dispersed in subhepatic space and right iliac fossa, these were taken out as much as possible. The ileal loop was isolated and a thorough abdominal wash with warm saline was given. Finally a Segmental Ileal Resection was performed followed by a Hand Sewn End to End Anastomosis. Drains were inserted into both Right and Left Iliac Fossae. Post operatively, typhoid fever diagnosis was verified serologically.

Patients was put on a third generation cephalosporin along with other supportive and symptomatic treatment. Condition of the patient improved and he passed stools on 5th postoperative day.

Typhoid Ileal Perforation

Typhoid Ileal Perforation












Read similar Posts:



A CASE OF TRAUMATIC ILEAL PERFORATION AND MESENTERIC TEAR
http://www.worldsurgeryforum.net/2016/05/a-case-of-traumatic-ileal-perforation.html

ILEAL PERFORATION DUE TO TYPHOID FEVER
http://www.worldsurgeryforum.net/2016/04/ileal-perforation-due-to-typhoid-fever.html

PseudoainhumPseudoainhum is a rare and poorly characterised phenomenon involving autoamputation of a digit associated with an identifiable or related disease process.

Ainhum does not have any predisposing condition associated while pseudoainhum is associated with predisposing conditions like trauma, leprosy, scleroderma, and diabetes. Other diseases which can cause pseudoainhum include psoriasis, scleroderma, and Raynaud disease. The constricting bands of pseudoainhum can also occur secondary to scar formation from trauma, burns, and other injuries.

It is thought that histological changes in pseudoainhum resemble those in ainhum, which initially presents with gross thickening of the stratum coreneum, and calcification of the ducts and the sweat glands. At a more advanced stage, there is chronic inflammation below the hyperkeratotic epithelium. As the fissure deepens due to this fibrotic reaction of collagen with a hyperkeratotic epidermis, tendons, vessels and nerves are compressed with eventual absorption of the bone by pressure. The latter stages are generally thought to be sterile and avascular


Pseudoainhum

These photos are of a female patient aged 36 years. She was a known case of traumatic paraplegia and congestive cardiac failure. The disease process was bilateral involving multiple toes.


Pseudoainhum



References:







- Amongst neural tube defects, the disorders involving spine, vertebral column and nerve roots are included in spinal dysraphisms. They can be classified as

  • Spina bifida aperta (open defects) 
  • Spina bifida occulta (closed defects)



- There is no specific treatment required for occult spina bifida if the abnormality is limited to the bone.



- Usually these deformities are found at the last lumbar vertebrae (L5) or at the first sacral vertebrae (S1)



- Faun's Tail is an abnormal lumbosacral hypertrischosis associated with spinal dysrasphisms



- A posterior lumbar bony defect is often present in 5% to 10% of the normal population, without any symptoms or deficits



- If other markers such as a tuft of hair, cutaneous hemangioma, or sinus tract are present, further investigations should be done.



- The term spina bifida occulta includes following:

  • Simple Spina Bifida Occulta: Mildest form of spina bifida. Usually asymptomatic.
  • Dermal Sinus: Dermal sinus tract from the cutaneous to spinal subarachnoid space. It can cause ascending infection
  • Diastematomyelia: Spinal cord is split into two hemicords, often by a bony or fibrous band that tethers the cord. Needs to be repaired surgically
  • Lipomyelomeningocele: There is fatty tissue in the spinal cord and in the spinal canal tethering the cord. Associated neurologic deficits, although uncommon at birth, usually develop later because of the tethering



Reference
Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice, 20e


Introduction

  • Autosomal dominant polycystic kidney disease (ADPKD) is one of the most common hereditary renal disorders characterized by varied manifestations including renal cysts, extrarenal cysts, intracranial aneurysms and dolichoectasias, aortic root dilatation and aneurysms, mitral valve prolapse, and abdominal wall hernias
  • Approximately one per 800-1000 population carries a mutation for this condition.
  • There is established association between ADPKD patients with ESRD and Renal cell carcinoma
  • The association of liver, colon and renal cancer with polycystic kidney disease without end-stage renal disease has also been reported
  • But only a few cases of gastric carcinoma happening in ADPKD patients have been reported.

Clinical Presentation

  • The patient was a 55-year- old male whose chief complaints were abdominal pain, vomiting, jaundice and weight loss. 
  • He was a known case of Autosomal dominant polycystic kidney disease. 
  • His father also had Kidney problems  and elder brother also is a k/c/o ADPKD. 

Investigations

  • Abdominal imaging studies showed bilateral polycystic kidneys, an irregular asymmetrical circumferential wall thickening of pylorus for a length of 5.6 cm with obstruction of the proximal bile duct and dilated intrahepatic biliary radicles.

Intraoperative Findings

  • A mass arising from pylorus was seen infiltrating into the lesser omentum along with involvement of porta hepatis lymph node with fibrosis and stricture at the confluence of hepatic ducts. 
  • However no compression or involvement of distal CBD was observed. 
  • Hence, the malignant stricture and fibrosis at the hepatic duct confluence was inferred as the cause for obstructive jaundice

Surgical Management

  • Roux en y hepaticojejunostomy, Subtotal gastrectomy, gastrojejunostomy, cholecystectomy and jejunojunostomy were done.

Histopathological Report

  • HPE revealed a well differentiated adenocarcinoma of the stomach. The duodenal stump and resected margins were free of tumour. Samples of fibrotic tissue from the site of obstruction at the confluence of hepatic ducts were negative for tumour infiltration as well.

Postoperative Period

  • Patient recovered uneventfully from surgery and the serum bilirubin reduced after which he was referred to medical oncology for chemotherapy.

ADPKD and Adenocarcinoma of Stomach

  • 4 cases of Carcinoma stomach were found in literature review which were reported in association with ADPKD. 
  • One of the case reports reported siblings with ADPKD, both developing adenocarcinoma of stomach.
References

Torres VE, Harris PC, Pirson Y (2007). "Autosomal dominant polycystic kidney disease.". Lancet. 369 (9569): 1287–1301. doi:10.1016/S0140-6736(07)60601-1. PMID 17434405
Dalgaard OZ (1957). "Bilateral polycystic disease of the kidneys; a follow-up of two hundred and eighty-four patients and their families". Acta Med. Scand. Suppl. 328: 1–255. PMID 13469269
Torres, Vicente; Harris, Peter C (2009). "Autosomal dominant polycystic kidney disease: the last 3 years“
Risk of cancer in patients with polycystic kidney disease: a propensity-score matched analysis of a nationwide, population-based cohort study: Yu, Tung-Min et al. The Lancet Oncology , Volume 17 , Issue 10 , 1419 – 1425
Halvorson CR, Bremmer MS, Jacobs SC. Polycystic kidney disease: inheritance, pathophysiology, prognosis, and treatment. International Journal of Nephrology and Renovascular Disease. 2010;3:69-83.
Two Cases of Gastric Carcinoma with Autosomal Dominant Polycystic Kidney Disease in the Same Family: KAYA, AKDAĞ, COŞKUNOĞLU, TÜRKELİ, YILMAZ. Turkiye Klinikleri J Med Sci 2012;32(6):1796-800
Carcinoma of the gastroesophageal junction associated with adult polycystic kidney disease: Aziz SA, Ahmad M, Shah A. Nephron. 1998;79(3):362-3.  PMID: 9678447

Patient was a 40 year old nulliparous female coming from a remote village with h/o infertility, a long standing mass in lower abdomen, feeling of heaviness and on/off constipation.

A smooth firm mass is seen and palpated extending from symphysis pubis to midway between umblicus and xiphisternum (equivalent to 32 weeks pregnancy).

The mass was firm, non tender and mobile with no fluctuation.


A Large Uterine Fibroid


Lower midline incision was put. The mass was apparent without any adhesions immediately after opening the abdomen.

A Large Uterine Fibroid

Uterus was grasped and pulled out of the incision.

A Large Uterine Fibroid

Hysterectomy with B/L Salpingo-Oophorectomy was done. On gross examination, the uterus was distorted and cut section showed multiple Intramural Fibroid nodules.


A Large Uterine Fibroid

Common  Exam Questions Related to Fibroid Uterus

What is the differential diagnosis?
  • Pregnancy
  • Full bladder
  • Haematometra/pyometra
  • Adenomyosis
  • Bicornuate uterus
  • Bilateral tubo-ovarian masses
  • Ectopic pregnancy
  • Pelvic Endometriosis
  • Endometrial carcinoma
  • Uterine sarcoma
  • Ovarian neoplasms

 What are the hormones implicated in growth of a fibroid?
Predominantly oestrogen dependant.
Other hormones implicated: Growth hormone, Human placental lactogen

The use of estrogen agonists is associated with an increased incidence of fibroid tumors, and growth hormone appears to act synergistically with estradiol in affecting the growth of fibroid tumors. Conversely, progesterone appears to inhibit their growth.

What are the management options for treatment of Fibroid uterus?
Asymptomatic women
Observation
Symptomatic women who desire fertility preservation
Nonsurgical treatment or myomectomy
Symptomatic women who do not desire future fertility but wish to preserve the uterus
Nonsurgical treatment or myomectomy, myolysis, or uterine artery embolization
Women who desire fertility preservation and have had a pregnancy complicated by uterine fibroid tumors
Myomectomy
Infertile women with distortion of uterine cavity
Myomectomy
Women with severe symptoms who desire definitive treatment
Hysterectomy


Reference:

http://www.aafp.org/afp/2007/0515/p1503.html
What is Skin Involvement or T4b ?
Edema (including peau d’ orange) or ulceration of the skin of the breast or satellite skin nodules confined to the breast.

What is not Skin Involvement or T4b ?
Dimpling of the skin and nipple retraction is not considered skin involvement.



Skin involvement in breast showing a skin nodule  surrounded by edema (peau d orange)
Skin involvement in breast showing a skin nodule 
surrounded by edema (peau d orange)
How does peau d’ orange appearance develop?
Localised edema (peau d’orange) develops when drainage of lymph fluid from the skin is disrupted by infiltration of lymphatics by metastatic cells.

-----------------------------------------------------------------------------------
Read more about Ca Breast:

WHAT IS THE REASON FOR PUCKERING OR SKIN RETRACTION IN BREAST CANCER?
http://www.worldsurgeryforum.net/2016/05/what-is-reason-for-puckering-or-skin.html

SKIN PUCKERING AND PEAU D ORANGE APPEARANCE IN BREAST CANCER
http://www.worldsurgeryforum.net/2016/05/skin-puckering-and-peau-d-orange.html

WHAT IS THE ACCURACY OF CLINICAL DETERMINATION OF AXILLARY LYMPH NODE METASTASIS IN CA BREAST?
http://www.worldsurgeryforum.net/2016/06/what-is-accuracy-of-clinical.html

MECHANISM OF METASTASIS FROM CA BREAST TO BATSON'S PLEXUS AND LIVER
http://www.worldsurgeryforum.net/2016/06/mechanism-of-metastasis-from-ca-breast.html


Traumatic Ileal Perforation with Mesenteric Tear
Traumatic Ileal Perforation with Mesenteric Tear
   
Case Presentation

A 45 year old male chronic alcoholic while under effect of alcohol was beaten with kicks and punches by two males. The patient had severe abdomen pain but he didn't go to a medical facility. Two days after sustaining this blunt trauma to the abdomen he presented to emergency with persisting abdomen pain, abdominal distension, fever and decreased urine output. But initially he gave a vague history of self fall while walking and did not give any clear history which suggested force of trauma. At presentation, patient was hemodynamically stable but his Blood urea was 116 mg/dl and his Serum Creatinine was 2.8 mg/dl.

Perforated ileal segment was resected
Perforated ileal segment was resected 
 Investigations
  • Focused assessment with sonography for trauma (FAST) revealed hemoperitoneum
  • NECT revealed mesenteric tear
Intraoperative Findings  
  • Hemoperitoneum, approximately 750 ml of blood with clots was sucked
  • A large traumatic ileal perforation and minimal soiling with intestinal contents
  • A mesenteric tear in the corresponding area of ileal perforation with large clots surrounding the area
Operative Intervention  
  • Hemoperitoneum was sucked
  • The perforation was closed temporarily with a clamp to prevent further soiling with intestinal contents
  • Mesenteric bleeder was clamped and ligated
  • Involved perforated segment of ileum was resected
  • End to end ileal anastomosis was done 
  • Thorough warm saline wash was given
  • Two drains were kept, each in morrison's pouch and pelvis
Postoperatively after 12 hours the urine output normalized and renal parameter came back to normal.
 





Important points about priapism

Priapism in a 60 year old man
Priapism in a 60 year old man
Case Presentation 
A 60 year old man presented with complaints of painful and persistent erection of 2 day duration which started without any sexual arousal. Patient was a known hypertensive since 5 years and was taking treatment regularly. There was no history of trauma or any other known medical illnesses. On examination the penis was tender, rigid and it felt indurated.

What is the Diagnosis? 
This patient is suffering from priapism. It is defined as an involuntary, prolonged erection unrelated to sexual stimulation and it is not relieved by ejaculation.

Definition of Priapism?
It is full or partial erection that continues for more than 4 hours beyond sexual stimulation or orgasms or is completely unrelated to sexual stimulation.
What are the types of Priapism? 
Types of priapism:
  • Low-flow or Ischemic or Veno-Occlusive
  • High-flow or Non-ischemic or Arterial
  • Stuttering Priapism
In Veno-Occlusive Priapism, there is initial occlusion of venous outflow  and subsequent cessation of arterial inflows.The condition is analogous to muscle compartment syndrome. It is an emergency, interventions beyond 48 to 72 hours of onset relieve erection/pain but have little benefit in preserving potency.

In Arterial Priapism, there is unregulated cavernous arterial inflow resulting from disruption of the cavernous arterial anatomy due to formation of arteriolar-sinusoidal fistula. The etiology is usually attributed to trauma. Typically, the corpora are tumescent but not rigid and the penis is not painful. It is not an emergency, spontaneous resolution or response to conservative therapy has been reported in up to 62% cases.

The term Stuttering priapism is used to describe a pattern of recurrent prolonged and painful erections in main with sickle cell disease.

Which is more common among the given types of priapism?

80% to 90% of clinically presented priapisms are low-flow disorders.

What are the symptoms and signs of priapism?

Case discussion on Subcutaneous Calcaneal Bursitis


Case Presentation:

A 60 year old male patient came with complaint of swelling and pain over posterior aspect of ankle. He thinks that it was caused by a blunt injury over the same site about 2 years back after which he developed the swelling which gradually grew in size to attain the current size and has been having chronic pain while walking ever since. The swelling is about 3x3cm in size, not warm, tender, firm and not freely mobile. Plain of the swelling is subcutaneous.On Xray there was no bony prominence corresponding to this swelling.

Case discussion on Subcutaneous Calcaneal Bursitis


Anatomy of Ankle Bursae

Pain at the posterior aspect of ankle is most commonly due to pathology at the posterior calcaneus, the Achilles (calcaneal) tendon, or the associated bursae. Following are the associated bursae [1]:
  • Subtendinous calcaneal bursa: Also called the retrocalcaneal bursa, situated anterior (deep) to the Achilles tendon, is located between the Achilles tendon and the calcaneus
  • Subcutaneous calcaneal bursa: Also called the Achilles bursa, it is found posterior (superficial) to the Achilles tendon, lying between the skin and the posterior aspect of the distal Achilles tendon

Case discussion on Subcutaneous Calcaneal Bursitis

Pathophysiology of Ankle Bursitis

Inflammation of the calcaneal bursae is most commonly caused by repetitive overuse and cumulative trauma, as seen in runners wearing tight-fitting shoes. Such bursitis may also be associated with conditions such as gout, rheumatoid arthritis, and seronegative spondyloarthropathies.

This is not same as Haglund's deformity. Haglund deformity, also known as a pump bump or Bauer bump or Mulholland deformity, is defined as bony enlargement formed at posterosuperior aspect of calcaneum. This deformity leads to retrocalcaneal bursitis [2].


References:

[1] Kachlik D, Baca V, Cepelik M, et al. Clinical anatomy of the retrocalcaneal bursa. Surg Radiol Anat. 2008 Mar 11
[2] http://radiopaedia.org/articles/haglund-deformity





Multiple choice questions on Obstructive Jaundice
Icterus

Case Presentation

A 27 year old male came with complaints of Jaundice for a duration of 2 months which was insidious in onset, gradually deepening in color, not intermittent and not associated with pain. He says his stool are lighter in colour than normal. He also had gradually distending abdomen from past 1 month and pedal edema -10 days. He now complaints of fever from past 2 days not associated with chills and rigors. He is a known chronic alcoholic but does not reports of any other medical illnesses.

He is febrile on examination. Gall bladder or any lump is not palpable. Abdomen is moderately distended and mildly tender.

His bilirubin total is 7.5 and direct is 3.8. Bile salts and pigments are postive in urine. SAP was found to elevated more than 3 times the normal value and mildly elevated ALT/AST . Usg Abdomen shows Ascites and chest X ray shows bilateral pleural effusion.

Q.1: What is the lowest level of bilirubin to detect jaundice in the sclera?


Q.2: What can be the cause of this presentation.
  1. Liver cirrhosis with spontaneous bacterial peritonitis
  2. Carcinoma of periampullary region with spontaneous bacterial peritonitis
  3. Acute Fulminant Viral Hepatitis
  4. Carcinoma Stomach with liver metastasis and peritoneal seeding
Give your responses in the comments section below. Explanation to be posted tomorrow.