Pneumoperitoneum is almost always pathognomonic of a perforated abdominal viscus requiring urgent surgical intervention. Spontaneous or non-surgical pneumoperitoneum is a rare clinical condition arising secondary to abdominal, thoracic, gynaecologic or idiopathic causes. In addition to good clinical judgement, an important component in the management process is to rule out other causes of pneumoperitoneum by performing appropriate investigations. We describe a 60-year-old man who presented with clinical features of pseudo-obstruction, following an injury to his back which was compounded by hypokalaemia. Roentgenography revealed massive pneumoperitoneum and colonic distension. As there were no overt clinical features of peritonitis, the patient was managed conservatively with parenteral nutrition and close observation. A water-soluble contrast enema and computed tomography of the abdomen were of no help in identifying the cause of his pneumoperitoneum but were helpful in eliminating the presence of hollow viscus perforation or an obvious inflammatory focus. The aetiology of pneumoperitoneum in our patient was most likely due to dissection of air through the distended colonic wall, secondary to large bowel pseudo-obstruction. The diagnosis of spontaneous or non-surgical pneumoperitoneum is one of exclusion and we stress the importance of relying on clinical parameters when managing such patients conservatively.
Primary malignant melanoma arising in the oesophagus is a rare condition with a dismal prognosis. The diagnosis is often made following surgical resection even though the endoscopic features may be pathognomonic. The classical treatment is oesophagectomy even though the advanced disease stage at the time of presentation and aggressive biological behaviour of the tumour usually results in a fatal outcome. We report the case of a male patient initially diagnosed with squamous oesophageal carcinoma and treated with conventional neo-adjuvant chemo-radiotherapy. Poor clinical and radiological response resulted in a review of the original histology confirming a diagnosis of primary malignant melanoma of the oesophagus. The subsequent alteration in management conferred the patient an improved quality of life. A short review of the literature on primary malignant melanoma of the oesophagus supplements this case report.
Occult mucosal prolapse syndrome, also known as the solitary rectal ulcer syndrome (SRUS) is uncommon. Due to its rarity, a misdiagnosis of rectal cancer is occasionally made as the clinical features may closely mimic those of rectal malignancy. We hereby report a case of SRUS in an elderly Malay gentleman who had primary symptoms of rectal bleeding with associated anaemia and anorectal pain. Even though the clinical features and specific investigations suggested the presence of rectal cancer, preoperative histological analysis failed to confirm this. In view of the intractable symptoms and rectal bleeding, a low anterior resection was performed. A detailed examination of the resected specimen intraoperatively, together with the histological report and awareness of this condition avoided the performance of an abdomino-perineal resection. Incidently coexisting malrotation of the sigmoid colon to the right side was discovered during surgery. This finding, which may be coincidental, has not been reported thus far in the medical literature. The patient's symptoms improved postoperatively with a subsequent uneventful recovery. A brief literature review supplements this case report.
Keywords: Mucosal prolapse syndrome, solitary rectal ulcer syndrome, rectal cancer
Haemangiopericytoma (HPC) is a rare tumour with a predilection for the central nervous system. Though previously thought to originate from the meninges and ventricular walls, HPC's are currently accepted as distinct mesenchymal neoplasms unrelated to meningiomas. Haemangiopericytomas have been previously reported to be associated with the production of insulin like growth factor II (IGF-II) and hypoglycaemia. A case of a 61-year-old poorly controlled diabetic lady with a rare presentation of an abdominal haemangiopericytoma is discussed. A laparoscopic assisted resection of the massive lobulated tumour arising from the parietal peritoneum with dense attachment to the diaphragm and the liver was performed with an uncomplicated postoperative recovery. Control of the patient's diabetes improved dramatically following surgery and the rare association of hyperglycaemia and HPC, which has not been previously described, is elaborated upon in this report.
An inguinal hernia that suddenly becomes irreducible may be secondary to a variety of other underlying conditions which can occasionally mislead the attending surgeon. Benign, inflammatory or neoplastic processes, as well as surgical emergencies such as intraperitoneal or retroperitoneal haemorrhage, have all been previously reported to mimic an inguinal hernia that suddenly becomes irreducible with or without clinical features of strangulation. We add an additional interesting presentation to this list in the form of a ruptured ectopic pregnancy, which is the first such case reported in the literature. A swelling in the groin may be much more complicated than it seems on superficial consideration and good clinical acumen is constantly required in managing such cases if a satisfactory outcome without any morbidity is to be expected.
Primary or idiopathic greater omental torsion remains a rare cause of acute surgical abdomen in adults and children. The aetiology is as yet unknown and the treatment of choice, once diagnosis is established, is resection of the torted omentum. We report our experience with three such cases encountered over the last five years, two of which were diagnosed and subsequently managed laparoscopically. The performance of diagnostic laparoscopy for acute abdominal pain of an undetermined origin may lead to an increased detection of this condition and subsequent therapeutic intervention.
Venous thromboembolism (VTE) has historically been perceived to be a rare disorder in Asia. However, new evidence has emerged recently that contradicts this perception. The question of routine VTE prophylaxis has been hotly debated in Asia due to disagreement on its incidence. We reviewed and analysed studies on postoperative VTE in Asian patients to determine if the condition was indeed rare and if the routine prophylactic measures as recommended by internationally accepted guidelines should be adopted in Asia.
It has been reported in the literature that the perception of crime at the neighbourhood level inversely affects the walking behaviour of individuals. On the other hand, the gated neighbourhoods are considered safe from crime, however, there is a lack of research on the association of the perception of crime and walking in gated neighbourhoods. Therefore, the objectives of the study reported in this paper were to investigate the association between the perception of crime and walking in gated and non-gated neighbourhoods. A questionnaire was used to collect the data on walking and the perception of crime in 16 neighbourhoods of Karachi Pakistan, 8 out of which were gated. Independent sample t-test and gamma tests were used for the data analysis. The results show that although there is a lower perception of crime in the gated neighbourhoods, yet the inhabitants of gated neighbourhoods engage in less physical activity comprising of walking. In spite of a greater perception of crime in non-gated neighbourhoods, higher values of walking were reported by the residents of those neighbourhoods. Therefore, it has been concluded that there does not exist a definite relationship between the perception of crime and walking behaviour at the neighbourhood level and the perceived safety from crime claimed by the proponents of the gated neighbourhoods does not encourage walking among the residents.
Idiopathic chronic anal fissure is believed to be a consequence of a traumatic acute anodermal tear followed by recurrent inflammation and poor healing due to relative tissue ischaemia secondary to internal sphincter spasm. This pilot trial compared the efficacy of a novel manufactured ano-coccygeal support attached to a standard toilet seat (Colorec) to the standard procedure of lateral internal sphincterotomy (LIS) for chronic anal fissure.
Meckel's diverticulum is a relatively common gastrointestinal entity which occasionally causes complications. Meckel's diverticulum is classically described to mimic acute appendicitis when inflamed as well as being a cause of unexplained luminal gastrointestinal bleeding. An unusual cause of spontaneous non traumatic haemoperitoneum found during surgery performed for a suspected acute appendicitis in a 22-year old female is described. The patient was found to have a significant haemoperitoneum due to a bleeding serosal vessel of a Meckel's diverticulum. The diverticulum was routinely excised. It was macroscopically and histologically devoid of inflammation. The bleeding vessel was not found to be abnormal or part of an arteriovenous malformation.
A retrospective cross-sectional study was carried out in a tertiary referral centre to determine the appropriateness of usage of emergency upper gastrointestinal endoscopy (EUGIE) with reference to the guidelines set by the American Society of Gastrointestinal Endoscopy (ASGE). EUGIE was defined as early, non-elective endoscopy performed for in-patients within 48 hours of acute hospital admission. The median age of the 668 patients was 55 years (age range 12- 90), 31% of whom had a previous upper gastrointestinal endoscopy. Bleeding in the form of haematemesis, melaena or anaemia was the most common indication (40.7%) for EUGIE. Eighty one percent of the procedures were judged appropriate by the ASGE guidelines. There was a statistically significant relationship between appropriateness and significant diagnostic yield (P<0.05). Procedures performed for melaena, symptomatic anaemia and haemetemesis led to greater significant diagnostic yield (P<0.05) and there was no difference in the yield between working-hours and after-hours EUGIE.
Dieulafoy's lesion is an uncommon cause of gastrointestinal haemorrhage. It may present with massive and life threatening bleed and although more common in the upper gastrointestinal tract, it is being increasingly reported as affecting the lower gastrointestinal tract. Diagnosis is usually achieved during proctoscopic and endoscopic visualization. In cases where there is profuse and torrential hemorrhage, angiography may help to confirm the diagnosis. There are a few treatment options available, all of which have a varying degree of success. More commonly than not, a combination of treatment is warranted as illustrated by our case. Recurrent bleeding may occur just as in cases of Dieulafoy's lesion affecting the upper gastrointestinal tract. Even though endoscopic visualization of the lower gastrointestinal tract in the presence of profuse lower gastrointestinal haemorrhage may not be possible, this important procedure should not be omitted as the bleeding source may be lying in a low and accessible location for prompt interventional haemorrhage control.
Perforation with extravasation of barium is a rare complication of contrast enema examination of the large bowel with a high associated mortality rate. The experience of performing a re-laparotomy in a patient previously exposed to barium peritonitis is even less common. We describe an elderly male patient with a Hartmann's procedure performed a year previously, presenting with peritonitis following barium enema evaluation of the proximal colon via an end descending colon stoma. Emergency laparotomy, segmental bowel resection and liberal peritoneal toilet resulted in a satisfactory outcome. The patient had a subsequent successful reversal of his Hartmann's procedure nine months later despite the presence of dense barium induced adhesions. This potentially preventable iatrogenic complication is discussed in this report, which is supplemented by a brief review of the English literature.
A 105-day experimental trial was conducted to assess different levels of dietary Aleo vera extract supplementation on water quality parameters, proximate composition, growth performance and haematological parameters of fry Oreochromis niloticus. Four different percentages of dietary leaf extract powder of Aleo vera (ALE) with a basal feed, designated as, i.e., T0 (Control group; without ALE), T1 (1% ALE), T2 (2% ALE), and T3 (3% ALE). Fish fry was reared in concrete tanks (7.0 m, 1.6 m, 1.0: L, W, H; water volume 11.2 m3/tank), with an average initial weight 4.04 ± 0.03 g/ fry, and each treatment was triplicated. Fry was randomly distributed at a stocking rate of 450 individuals/ tanks. The water quality parameters revealed that temperature, pH, salinity, dissolved oxygen (DO) and nitrates were found in a promising range as given by FAO/WHO limits. However, the record values obtained for Electric Conductivity (EC), Total dissolved solids (TDS), and alkalinities were not found in all tanks' suitable range according to FAO/WHO limits. The results revealed a significant impact of different percentages of dietary ALE supplementation on fry's body composition and haematological parameters. Moreover, the final body weight, final body length, average daily weight gain (g), net weight gain (g) and specific growth rate (%) were significantly higher (p