Huge gastric and ileal trichobezoars causing small bowel obstruction

The bezoar is the accumulation of undigestible food or fibre in the digestive tract, most commonly in stomach and proximal small bowel. Trichobezoar is an accumulation of hair. They may present as an independent mass in small bowel or with or without an extension into the small bowel. The trichobezoars are well described, in terms of surgical, diagnostic, and therapeutic procedures. However, there are very few reports on psychiatric literature and a dual presentation of gastric and ileal trichobezoars. The authors present a case report of a gastric with an ileal trichobezoar that is rarely reported in literature. A young girl with a history of trichophagia presented with features of small bowel obstruction. On physical examination, there was abdominal distension with a huge mobile mass on left side of umbilicus extending up to the epigestrium. There were dilated small bowel loops on abdominal radiograph. Ultrasound-abdomen also showed fluid-filled dilated small bowel loops. She was further investigated with CT scan abdomen, which showed a large mass occupying whole of the stomach and another mass in distal ileum causing small bowel obstruction, suggestive of trichobezoar. Through anterior wall gastrotomy, huge trichobezoar was removed from stomach; and through distal ileal entrotomy, ileal trichobezoar was removed

Bile duct injuries and outcomes: a retrospective medical record review

Objective: To report on our experience of cholecystectomy associated bile duct injuries and observe factors influencing outcomes

Study Design: Simple descriptive study

Place and Duration of Study: Surgical unit IV, Military Hospital [MH] Rawalpindi, over a period of seven years from 01-01-2005 to 1-12-2012

Material and Methods: Eighty eight patients who underwent repair of bile duct injuries during this period were included in this study. Patients referred from class 'W and 'C' hospitals to our institute were also included

Results: Fifteen immediate repairs [0-72 hours] post cholecystectomy, forty eight intermediate repairs [72hrs-6wks] and twenty five late repairs [> 6 wks] were performed [table-1]. Short term morbidity was higher in patients with upper biliary tract injury [p=.04].The most common long-term complication was biliary stricture, which occurred in 28 patients [31.8%]. Patients with bile duct injuries [BDIs] repaired in intermediate period were more prone to develop stricture of biliary tree than those repaired in immediate or late period [p=.03] [table 3]. Long term morbidity was also higher in patients who presented with bile contamination of peritoneum [p=.03] and had sustained complex biliary tract injuries [E4/E5] [p=.03].The overall morbidity and mortality rate was 31% and 3% respectively

Conclusion: We observed that complex hilar injury, presence of intra-abdominal bile and timing of BDI repair is an important predictor of long-term outcome. Injuries repaired in early [0-72hrs] or late period [>6wks] were less likely to develop biliary stricture as compared to injuries repaired in intermediate period [72hrs-6wks]. Moreover complex hilar injuries and intra-abdominal bile at presentation increases the possibility for development of late biliary stricture

Spectrum of diseases in acute intestinal obstruction

To determine the etiological spectrum of acute intestinal obstruction in our clinical setup Military Hospital Rawalpindi. Descriptive study. Surgical department of Military Hospital, Rawalpindi from Jul 2012 to Jul 2013, over a period of about 1 year. A total of 120 patients with acute mechanical intestinal obstruction who underwent laparotomy were included in our study while those with non-mechanical intestinal obstruction like history of trauma and paralytic ileus were excluded from the study. All the patients were selected by non-probability purposive sampling technique. Emergency laparotomy was done and operative findings were recorded. A total of 120 patients with mechanical intestinal obstruction were included in this study out of which 93 [69.17%] were female and remaining 27 [30.83%] were males. Male to female ratio was 1:2.24. Age range of patients was 22-85 years. Out of 120 patients operated for acute intestinal obstruction post-op adhesions were found in 37 [30.83%] patients followed by intestinal tuberculosis in 23 [19.17%] patients, obstructed inguinal hernias in 13 [10.83%], gut malignancies in 15 [12.5%], Meckel's diverticulum with bands in 7 [5.83%], volvulus in 7 [5.83%], perforated appendix in 6 [5%], intussusception in 2 [1.7%], inflammatory bands in 5 [4.17%], trichobezoar and faecal impaction in 2 [1.7%] while in 3 [2.5%] patients no definite cause was found. Post-op adhesions are the commonest cause of mechanical intestinal obstruction in our setup followed by intestinal tuberculosis as second most common clinical pattern of presentation

Gall bladder tuberculosis: a case report

An 80-year old man presented with mild right upper quadrant abdominal pain of six months duration. The pain exacerbated off and on. Clinical examination of the patient revealed a mildly tender right hypochondrium. No mass or enlarged viscus was palpable. Ultrasonography of abdomen revealed a contracted gallbladder containing multiple calculi. Chest X-ray was suggestive of chronic obstructive airway disease [COAD]. His hemoglobin was 12.6 gm/dl and total leukocyte count was 5.6x10e9/L. Neutrophils were 65% while lymphocytes were 30%. Blood glucose levels and liver function tests were within normal limits. Hepatitis B surface antigen and anti-HCV antibodies were negative. Peroperatively, gallbladder was seen to be contracted and had thickened walls. Its serosal surface was granular. The greater omentum and mesentery were studded with nodules. No spread was seen into the gallbladder fossa or into the liver. Lymph node of Lund and those in the mesentery were enlarged. Gallbladder contained multiple small calculi. The resected gallbladder and a biopsy of greater omentum were sent for histopathology, which revealed gallbladder tuberculosis with caseating granulomas, as well as tuberculous omentitis. Patient is on anti-tuberculosis therapy and is improving steadily

Skip lesions in intestinal tuberculosis

A young lady of 20 years presented with profuse vomiting and absolute constipation of three days duration. She had history of recurrent abdominal pain with vomiting associated with intermittent constipation, abdominal distension and weight loss for the last one year. Conservative management led to no improvement. There was no past history of diarrhea, bleeding per rectum, cough or hemoptysis. General physical examination showed her to be emaciated, afebrile and moderately dehydrated. Her weight was 38 kg. Abdomen was grossly distended with tinkling bowel sounds. No other general or specific physical abnormality was found. Her ESR was 25 mm at the end of 1st hour [Westergren method]; hemoglobin was 9.3 gm% with a hematocrit of 30%; TLC was 8500/cm with 25% lymphocytes and the plain x-ray abdomen showed multiple air-fluid levels in small intestine confirming the diagnosis of intestinal obstruction. She was prepared for emergency surgery, which revealed seven tight strictures in the jejunum and ileum starting at 6 inches from the duodenojejunal flexure and ending 4 inches from the ileocaecal junction. Although the proximal jejunum was dilated, the intervening segments of intestine between strictures were absolutely normal in shape and thickness of wall, colour and texture varying in length from 7 to 18 inches. Gross examination of the mucosa showed transversely placed fibrous strictures causing stenosis without adjacent ulceration, edema or congestion. Mesenteric lymph nodes were enlarged. The rest of the gut was normal. All strictures were managed by stricturoplasties. A piece of the involved gut and an enlarged lymph node from the mesentery was taken as biopsy. Postoperative recovery was smooth. Considering the history and the gross appearance of the intestinal mucosa, anti-tuberculous [TB] chemotherapy was started. Histopathology revealed caseation and Langhan's type of multinucleate giant cells in both the specimens. Ziehl Nielson [ZN] staining of the intestinal biopsy showed acid-fast bacilli, confirming the clinical diagnosis of tuberculosis. Anti-TB drugs were continued for 9 months. During this period her weight increased to 60 kg and abdominal symptoms disappeared. She was asymptomatic 6 months after cessation of drugs

Xanthogranulomatous pyelonephritis in a child

A case of xanthogranuloma of kidney in a child is presented, which was clinically diagnosed as a case of renal tumor. Nephrectomy with subsequent histopathology revealed Xanthogranulomatous Pyelonephritis

Horse hair and tetanus. A case study

A case of tetanus is reported. The disease was contracted from a horse hair used by a quack to excise a mole. The causative organism, Clostridium tetani, resides in horse hair and excreta. Unhealthy practices still prevalent in rural areas of Pakistan which can lead to this fatal disease

Intussusception of vermiform appendix. A case study

A case of intussusception of vermiform appendix diagnosed on sonography is reported. Appendectomy was carried out through an elliptical incision around the base of the appendix recovery was smooth