Role of laparoscopy in evaluation of abdominal pain

Objective: To evaluate the diagnostic efficacy of laparoscopy in ill-defined recurrent chronic abdominal pain

Study Design: Prospective study

Place and Duration of Study: Surgical department, Military Hospital Rawalpindi, from Jul 2011 to Dec 2013

Material and Methods: A total of 102 patients who presented to surgical department with chronic recurrent abdominal pain of unknown etiology and underwent diagnostic laparoscopy were included in our study. Patients with acute onset of abdominal pain, hemodynamically unstable, pregnant or those in which diagnosis can be made by radiological techniques were excluded from our study. Patient's demographic data, clinical findings and laparoscopic findings were recorded. Finally data was analyzed by using SPSS version 21

Results: Out of 110 patients 96 were female while remaining 14 were male. The age range of the patients was 20-70 years with mean age of 50 +/- 10 years. The most common site of pain was lower abdomen while mean duration of abdominal pain was 34 weeks. Laparoscopic findings include acute recurrent appendicitis in 32 [29.09%] patients, cholecystitis with biliary sludge in 14 [12.72%], pelvic inflammatory disease in 12 [10.90%], ovarian cyst in 11[10%], adhesions in 10[9.09%], intestinal tuberculosis in 8 [7.27%], mesenteric lymphadenitis in 7 [6.36%], lymphoma in 4 [3.63%], ectopic pregnancy in 3 [2.7%], CA gallbladder in 2 [1.81%], meckels diverticulum in 2 [1.81%], endometriosis in 2 [1.81%] and crohns disease in 1 [0.9%] patients. Mean operative time was 48 min while average hospital stay was 2-3 days. No major complications were noticed

Conclusion: Laparoscopy in our clinical setup has significant role in diagnosing cases of vague abdominal pain which cannot be diagnosed by routine investigations

Diagnostic values of gene expression of cytokeratin - 19 mrna and mammaglobin mrna in breast cancer patients using real-time polymerase chain reaction

Breast cancer is the most frequent cancer in women. It constitutes almost 20% of all malignancies in women. Currently it affects approximately 6% of the female population. Even before clinical detection of a primary tumour, cancer cells can invade the adjacent structures from where they travel through lymphatic and blood vessels as circulating tumour cells [CTCs]. CTCs colonize distant organ sites as disseminated tumour cells [DTCs] and eventually form microscopic deposits [micrometastasis < 2 mm in diameter], which may remain dormant, but then ultimately lead to an overt metastatic disease. Cytokeratins [CKs] have become the most widely accepted protein markers for the detection of epithelial tumour cells in mesenchymal tissues, BM, blood and lymph nodes. Based on its breast cancer-association and somewhat unique breast-specific pattern of expression, mammaglobin was believed to be an excellent candidate for a novel and clinically useful breast tumor marker, especially in detecting micrometastasis. This study was performed on one hundred female Individuals. They classified into: Group I: 20 apparently healthy females as control group. Group II: 20 females with stage I breast cancer . Group HI: 20 females with stage II breast cancer. Group IV: 20 females with stage III breast cancer. Group V: 20 females with stage IV breast cancer. The following specific investigations were done for all the studied persons:-Cancer Antigen 15-3 [CA15-3] and Carcinoembryonic Antigen [CEA] using chemilmnmescent immunometric assay [IMMULITE 1000 Analyzer]. Cytokeratin-19 mRNA [CK-19] mRNA and mammaglobin mRNA by Real-time polymerase chain reaction [RT-PCR]. In group I [control group]: All the 20 healthy control females had low expression values for CK-19 and Mammaglobin. In group 2 [stage I breast cancer]: 35% of patients had over expression values for CK-19 and 20% had over expression values for Mammaglobin. In group 3[stage II breast cancer]: 47.4% of patients had over expression values for CK-19 and 47.4% had over expression values for Mammaglobin. In group 4 [stage III breast cancer] 68.4% of patients had over expression values for CK-19 and 73.7% had over expression values for Mammaglobin. In group 5 [stage IV breast cancer]: 95% of patients had over expression values for CK-19 and 95% had over expression values for Mammaglobin. Our findings support that all patients with breast cancer should be evaluated by CK-19 and Mammaglobin as a regular laboratory assessment beside the routine tumour markers specially in early stages of breast cancer to detect CTCs at the time of diagnosis

Transforming growth factor-beta1 gene expression in hepatocellular carcinoma: a preliminary report

The transforming growth factor [TGF]-beta signalling pathway plays a dual role in hepatocarcinogenesis. It has been recognised for its role as a tumour suppressor as well as a tumour promoter depending on the cellular context. The aim of this study was to investigate the clinical significance of serum TGF-beta1 level and TGF-beta1 messenger RNA [mRNA] in the peripheral blood of liver cirrhosis and hepatocellular carcinoma [HCC] patients as noninvasive biomarkers in diagnosing HCC. Twenty patients were allocated to each of the liver cirrhosis and HCC groups, in addition to 20 healthy volunteers. TGF-beta1 gene expression in peripheral blood was quantitated using real-time polymerase chain reaction [PCR], while serum TGF-beta1 was analysed using enzyme-linked immunosorbent assay [ELISA]. TGF-beta1 gene expression was significantly lower in HCC patients [median 0.401 [0.241-0.699] fold change] than in liver cirrhosis patients [median 0.595 [0.464-0.816]] [p = 0.042] and normal controls [median 1.00 [0.706-1.426] fold change] [p = 0.001]. TGF-beta1 gene expression showed significant positive correlation with serum TGF-beta1 [r = 0.272, p = 0.036] and significant negative correlation with alpha-fetoprotein [AFP] [r = ?0.528, p = 0.001]. Receiver operating characteristic [ROC] analysis was conducted for TGF-beta1 gene expression in comparison with AFP. The area under the curve for TGF-beta1 gene expression was 0.688 [95% CI = 0.517-0.858] [p = 0.042] and AFP was 0.869 [95% CI = 0.761-0.976] [p = 0.001]. The sensitivity and specificity of TGF-beta1 gene expression were 65% and 75%, respectively, at a cutoff value of 0.462 fold change. TGF-beta1 gene expression in the peripheral blood may be used as a molecular marker for the diagnosis of HCC. Additional studies on a large-scale population are necessary to gain greater insight into the impact of TGF-beta1 gene expression in the pathogenesis of HCC

Screening for autoimmune diseases in type 1 diabetes: low incidence of adrenal insufficiency

Primary Adrenocortical insufficiency [Addison's disease] is a potentially fatal condition that often develops incidentally and can be easily overlooked. Although rare in the general population, it is more common in patients with type 1 diabetes mellitus [T1D]. In this study, we reviewed our experience with the occurrence of associated adrenal insufficiency [AI] in children with T1D over 15 year's period at King Khalid University Hospital [KKUH], Riyadh, Saudi Arabia. This is a retrospective hospital based study, included children and adolescents with T1D at KKUH in the period January 1995-December 2012. All patients were serologically screened for Celiac and thyroid diseases. Adrenal function was assessed at the time of diagnosis, and annually thereafter by measuring serum cortisol and adrenal corticotrophic hormone [ACTH] using the available commercial kit. Adrenal cortex antibodies [AAA] test was done by Bioscientia laboratory, Germany, in one patient. In a cohort of 305 children and adolescents with T1D at KKUH, only one patient was found to have AI as a part of autoimmune polyendocrine syndrome type 1. Thyroid functions were abnormal in 65 [21.3%] patients. Of these, 26 [8.5%] patients have evidence of overt hypothyroidism and 39 [12.8%] patients had subclinical hypothyroidism. In twenty-six patients [8.5%], the intestinal biopsy results were positive for CD. There is no international consensus on the issue of screening for AI in children with T1D. In our experience, we do not favour screening for AI in children with T1D unless there is a clear risk factor

first Egyptian experience using new self-expandable metal stents in acute esophageal variceal bleeding: pilot study

Balloon tamponade has been widely available in emergency situations of acute variceal bleeding. To lessen the complications of Balloon tamponade, a new special type of stent for exclusive use in acute variceal bleeding has been developed. This study aims to investigate the effectiveness and safety of the new self-expandable metal stents [SEMS] in the initial control of acute variceal bleeding. We also hypothesized that using SEMS can bridge the acute bleeding episode converting endoscopic management by sclerotherapy or band ligation to an elective procedure. Twenty patients with acute variceal bleeding were included in the study and 16 of them were allocated to receive stent treatment. Stent deployment was successful in 15 of 16 patients [93.75%]. Technical errors were reported in 3 [18.75%] patients. Initial control of variceal bleeding was reported in 14 [out of 16] [87.5%] patients. The mean duration of the procedure was 10 [ +/- 6] min. Mortality was reported in 4 [25.0%] patients. SEMS is a safe and effective mean to control acute variceal bleeding

Anterior versus conventional surgical approach for hepatic resection of large hepatocellular carcinoma

Hepatic resection of a large HCC represents a surgical challenge. In patients with large HCC in the right liver, the conventional technique for hepatectomy, i.e., mobilization of the right liver from the retro peritoneum and anterior surface of the inferior vena cava may be difficult because of the tumor volume and local adhesions. Likewise, even if the mobilization can be accomplished, the forceful manipulation of the liver can result in tumor rupture and dissemination of malignant disease. To report the efficacy of using the anterior approach versus the conventional approach, in surgical resection for large hepatocellular carcinoma [HCC] in terms of surgical and long-term outcomes. This was a retrospective study of 126 consecutive patients who underwent hepatic resection with curative intent for large right HCC >/=7 cm between 2000 and 2006. The 36 patients who had anterior approach were compared with the remaining 90 patients who had conventional approach. The median follow-up periods after hepatectomy was 36 months [range, 6 to 132 months]. Clinicopathological features and surgical results were analyzed and prognostic factors were evaluated by multivariate analysis. There was no significant difference between the 2 groups as regard clinical, laboratory and pathological parameters apart from gender. The operative results had shown a comparable proportion of patients experienced massive operative blood loss and postoperative complications in the 2 groups. The AA group had a lower recurrence rate [P = 0015], better disease-free survival [DFS] [P = 0001] and overall survival than the CA group. Our study identified that the anterior approach is a prognostic factor of both overall survival and disease-free survival for large HCC >/=7cm. The anterior approach is a safe and effective technique for right hepatic resection for large HCC and achieves more advantageous long survival outcome over the conventional approach

Etiology of pleural effusion among adults in the State of Qatar: a 1-year hospital-based study

There have been no systematic studies of diseases causing pleural effusion in Qatar. This prospective, hospital-based study involved all adult patients [> 15 years] with pleural effusions who were admitted to referral hospitals over a 1-year period. A total of 200 cases of pleural effusion were identified [152 males and 48 females]; mean age 45.1 [SD 18.5] years. A majority of patients [73.5%] were non-Qataris, mostly from the Asian subcontinent. The most frequent cause of pleural effusions was tuberculosis [32.5%], followed by pneumonia [19%], cancer [15.5%] and cardiac failure [13%]. The most frequent cause of malignant effusion was bronchogenic carcinoma [38.7%], whereas Gram-positive organisms were the most frequent isolates from empyema fluid [62.5%]. Histological examination and culture of pleural biopsy were the most useful diagnostic workup for tuberculosis effusions, whereas repeated cytological examination of pleural fluid and pleural biopsy were most useful for malignant effusions

[Polyarteritis nodosa with a spontaneous recovery]

The periarteritis nodosa [PAN] is a serious necrotizing vasculitis. Healing is, classically, obtained after a long-term treatment using corticosteroids and immunosuppressive agents. Purpose: Reporting the case of a NAP or was spontaneous healing without having recourse to any immunosuppressive treatment. We report an observation of a patient aged 27 monitoring for manic-depressive psychosis hospitalized for a fever during the course associated with high blood pressure [hypertension], a weight loss, asthenia and myalgia. Biology was a biological inflammatory syndrome [SIB], a creatinine 1 15p mol/1. The survey infectious and immunological balance were negative. The arteriography showed a strongly evocative of the NAP. We have seen no sign of poor prognosis. The recovery was spontaneous after a short period of evolution with an amendment clinical and biological weapons. The patient was put under anti-HTA and reviewed regularly to the consultation. An analogy is drawn between such developments and already reported in some cases of viral PAN. The actual frequency of self-limiting PAN is unknown. The scarcity of cases reported in the literature may in part be attributed to ignorance

Cystic hygroma as a rare cause of obstructive sleep apnea

A 16-year-old female presented with a seven-month history of episodic cessation of breath during sleep, associated with loud snoring and bluish discoloration of lips. She was a known case of cystic hygroma since birth with many surgical interventions and multiple relapses, the last having been laser therapy of a laryngeal cyst seven months previously. She had obvious throat scarring and a small cyst in soft palate. On the right side of the neck there was a non-tender soft tissue mass 6 x 4 cm in diameter and decreased breath sounds on auscultation of the right upper zone of the chest. MRI of the neck and chest showed a mass involving the right side of neck to the upper part of the chest and severe narrowing of the upper airway at the base of the tongue. A sleep study confirmed obstructive sleep apnea. She was referred to the UK for further surgery and treatment and died suddenly while there. The rare association of cystic hygroma and sleep apnea is reviewed

Preeclamptic toxemia in chlamydia pneumoniae seropositive pregnant women

Women who develop preeclampsia may have an intense inflammatory response which may be caused by a concurrent or preceding inflammatory stimulus such as infection. This study was conducted to test the hypothesis that there is an association between Chlarnydia pneumoniae [C.pneumoniae] immunoglobulin [Ig] G seropositivity and development of preeclampsia in pregnant women. A prospective observational study was carried out on 355 healthy pregnant women attending the outpatient clinic at Ain Shams University Maternity Hospital. All women were normotensive primigravidae after 20 weeks of gestation. A single venous blood sample was collected from each of these women and tested for the presence of C.pneumoniae specific IgG antibodies using microimmunofluorescence technique [MIF]. Subsequently, women were classified as either seropositive or seronegative. Women in both groups were followed-up to detect the development of preeclampsia. A total of 248 women continued follow-up till delivery and were enrolled in the study. Seropositive group had a higher incidence of development of preeclampsia; 10% [11 cases developed preeclampsia of 107 seropositive women], compared to seronegative group; 2.8% [4 cases of 141,] and this difference was statistically significant using Chi-square test [p<0.05]. The longitudinal data of this study suggest a possible association between C.pneurnoniae seropositivity and preeclampsia and also support the evidence on infection hypothesis for the development of preeclampsia

Prevalence of dyslipidemia in patients with type 2 diabetes in Jordan

To determine the frequency and patterns of dyslipidemia in patients with type 2 diabetes mellitus [DM] and to estimate the effects of sociodemographic and clinical variables on dyslipidemia. The setting took place in The National Center for Diabetes, Endocrinology and Genetics [NCDEG] at the University of Jordan, Amman, Jordan. The NCDEG is the only referral center in the country; therefore, the patients represent the population in different parts of the country. A cross-sectional design was used. A total of 702 patients with DM from the NCDEG aged >/= 20 years were consecutively enrolled between June 2005 and July 2006. Medical record abstraction of sociodemographic, clinical, and laboratory data was performed. The frequency of hypercholesterolemia was 77.2%, low high-density lipoprotein [HDL] was 83.9%, high low-density lipoprotein [LDL] was 91.5%, and hypertriglyceridemia was 83.1%. Females had greater abnormalities in lipid profiles. High LDL-cholesterol was the most common dyslipidemia in combination [91.5%] and in isolation [12.8%]. Gender and hemoglobin A1C [HbA1c] predicted high total cholesterol; age and hypothyroidism predicted low HDL-cholesterol, gender predicted high LDL-cholesterol; and use of beta-blockers predicted high triglycerides. Over 90% of patients with type 2 DM had one or more types of dyslipidemia. The most common dyslipidemia in our study was high LDL-cholesterol and high triglycerides as reported in the literature. We recommend aggressive drug management, education, counseling, and behavioral interventions

diagnostic value of monoclonal antibody panel in cases of Hodgkin's lymphoma

The interface between Hodgkin's lymphoma [HL] and B-cell NHL has become more ambiguous in recent years. Yet, the clinical presentation, prognosis, and treatment requirement of Hodgkin's lymphoma are very different from most B-cell NHL. Thus, distinguishing between those lymphomas is still mandatory. Reviewing and immunophenotyping [using a monoclonal antibody panel] of cases diagnosed by routine histologic sections stained with hematoxylin and eosin [H and E] as Hodgkin's lymphoma, subtyping the cases in view of the new classification based on morphologic and immunophenotypic data, as well as studying the efficacy of human fascin antibody as a new marker for Reed-Sternberg cells. All cases were submitted to pathological examination of the routine H and E stained section as well as immunohistochemical evaluation of fascin, CD30, CD 15, CD20, and CD3 expression with subsequent re-evaluation of cases and establishing a final diagnosis based on morphologic and immunophenotypic data. In the present work, positive immunostaining for fascin was expressed in 97.7% of classic HL, CD30 in 80.9%, CD 15 in 70.2%, and CD20 in 10.6%. Only 26 cases [57.7%] showed coexpression of CD30 and CD15. After the review of immunohistochemical slides the diagnosis was confirmed in 37 cases of classic HL. Problematic cases were reclassified into CHL of mixed cellularity subtype [2 cases], CHL of lymphocyte rich subtype [2 cases], and CHL of the lymphocyte depletion subtype [2 cases]. Two additional cases were classified as T-cell rich large B-cell lymphoma [TCRBCL]. Two cases remained unclassified after immuno staining. The present study emphasized that immunohistochemistry supports and refines the H and E based diagnosis of Hodgkin's lymphoma and that Fascin is a sensitive marker for RS cells and may be used to differentiate between Hodgkin's and non-Hodgkin's lymphoma in difficult cases. Furthermore, complete immunohistochemical panel is needed to distinguish between T-cell rich B-cell lymphoma and lymphocyte rich-classic Hodgkin's lymphoma whether nodular or diffuse taking into consideration that absence of CD 30 or CD 15 immuno staining or expression of CD20 does not 'rule out the diagnosis of classic Hodgkin 's lymphoma and that coexpression of CD 30 and CD 15 when coupled with CDS expression necessitates complementary studies

Adult onset diabetes mellitus in hepatitis C virus infection

There is growing evidence to suggest an association between hepatitis C virus [HCV] infection and diabetes, two common disorders that cause devastating long-term complications in a signficant number of patients. Several reports have found a high prevelance of HCV infection among diabetic patients. Additionally, a high prevelance of diabetes has also been reported in HCV- infected patients in comparison with other liver diseases. On the other hand some authors have not observed an association between HCV infection and diabetes, while others found that diabetes mellitus type 2 occurred with increasing frequency among patients with hepatitis C and this was associated with family history of diabetes mellitus. HCV seropositivity among patients with type 2 diabetes mellitus is higher than in the general population. Aim of work: Is to study the association between HCV infection and diabetes mellitus. This study included 410 consecutive patients with chronic liver diseases. They were attending the outpatient clinic of the National Hepatol-ogy and Tropical Medicine Research Institute and Aswan Teaching Hospital in the period from May 2004 to July 2005. Their ages ranged from 20-60 years. They were 304 males and 106 females. Patients were classified into 3 groups. Group A consisted of 220 non cirrhotic patients with HCV +ve. Group B consisted of 110 cirrhotic patients with HCV +ve. Group C consisted of 80 patients all are -ve for HCV Ab. Type2 diabetes was diagnosed as a fasting plasma glucose level [7.0mmol/L [126 mg/L] or on treatment with oral hypoglycaemic agents. It was found that distribution of diabetes mellitus between group A and B [HCV +ve] and group C [HCV Ab -ve] were 21.21%, 27.27%, 12.5% in respect order. There were no significant difference between AST levels, ALT level, BMI and diabetes mellitus. we have found an association between diabetes mellitus and HCV infection. It remains to be determined whether an HCV infection leads to diabetes mellitus or vice versa

Complication rate of tram flap breast reconstruction in obese patients

Transverse rectus abdominis myocutaneous [TRAM] flap is one of the common techniques used for breast reconstruction. Yet, it might carry certain risks when performed in obese patients. This study is a trial to quantify such risks. The records of 22 women with locally advanced breast cancer who had undergone unilateral breast reconstruction with the transverse rectus abdominis myocutaneous [TRAM] flap at the Department of Surgery, Alexandria University, were analyzed to determine what effect obesity had on the rate of complications. Patients were categorized into obese and non-obese according to height weight index. Ten patients were obese [group 1] and 12 were non-obese [group 2]. The overall complication rate was 41.7%. In obese patients six patients developed complications [60%] as compared to three non-obese patients [25%]. There was a trend for all forms of complications to be higher in the obese regarding wound sepsis, abdominal wall competence [bulging, hernia and pseudo-hernia], partial flap necrosis and chest infection. Ultimately most obese patients resolved these complications and obtained results that were comparable to the non-obese. The findings in this study suggest that the complication rate of TRAM flap breast reconstruction does increase with obesity; nevertheless, since the difference did not reach the level of significance, they remain acceptable candidates and should not be denied the procedure on grounds of obesity alone

Identifying harmful birth attendant and home care practices during the antenatal, peripartum and postpartum period in Egypt

Harmful practices by birth attendants during and shortly after birth, and poor practice in the home during the first week of life, may contribute to high neonatal mortality rates in Egypt. Inability of birth attendants and mothers to identify neonatal danger signs is also an issue. In this study 217 recently-delivered mothers were interviewed about their delivery and home care practices. Some good delivery care practices were identified, including routine hand-washing by most birth attendants, sterile umbilical cord care in most cases, and postnatal visits from the birth attendant in most cases. However, a number of deficits in care and potentially harmful practices were found: poor aseptic procedures, delivery of one-third of women with complications in the home; pulling on the umbilical cord to hasten delivery of the placenta and hanging the neonate upside-down by the legs during resuscitation. Some postnatal care practices were in also accord with generally agreed-upon standards of care, such as prompt initial feeding, feeding of colostrums and most bathing practices. Substandard care practices among mothers were: a lack of hand-washing before neonatal care; lack of exclusive breastfeeding including supplemental feeds to half of newborns at the first feeding; and a lack of aseptic cord care. The mothers' assessment of the health of their newborns was in good agreement with the incidence of signs of potentially serious illnesses, suggesting that advice they received has been appropriate. Based on these findings, priorities for future investigation are proposed

Cholestasis in human fascioliasis in Dakahlia governorate, Egypt

This study was conducted to assess cholestasis in human fascioliasis. Twenty five patients, passing Fasciola eggs, were compared to twenty age- and sex-matched healthy controls. All were subjected to thorough clinical examination, stool analysis, complete blood picture, liver function tests [AST, ALT, SAP, GGT and total serum bilirubin]. Autoimmune and viral hepatitis [HCV and HBV] were excluded. All cases were subjected to radiological examinations [chest X-ray and abdominal ultrasonography]. The study revealed significant elevation of liver enzymes in the patients compared to the controls. Calcular and non-calcular cholecystitis were common findings among patients [32% and 24%, respectively]. Ascites [4%] and dilated intrahepatic biliary radicals [32%] were encountered; pleural effusion was detected by chest X-ray in 20% of cases. So, fascioliasis should be considered in the diagnosis of cholestasis in Fasciola endemic areas