Topical diltiazem hydrochloride and glyceryl trinitrate in the treatment of chronic anal fissure

To compare the symptomatic relief, healing and side-effects of topical diltiazem [DTZ] and glyceryl trinitrate in the treatment of chronic anal fissure. Randomized controlled trial. The Surgical Outpatient Department of Civil Hospital, Karachi, from March 2006 to February 2007. Patients with chronic anal fissure were included in the study and randomized to two groups. One group was administered topical 2% diltiazem hydrochloride and other was given 0.2% glyceryl trinitrate [GTN], perianally twice daily for 8 weeks. Patients with anal fissure due to other diseases like inflammatory bowel disease, malignancy, sexually transmitted diseases, previous treatment with local ointment or surgery; patients who required anal surgery for any concurrent disease like hemorrhoids, pregnant women and patients with significant cardiovascular conditions were excluded. There were four follow-up sessions during the course of treatment. Healing and side-effects were recorded. Analysis was done by SPSS version 10 on intention-to-treat basis. Chi-square was used where appropriate. Eighty patients with symptomatic chronic anal fissure were included in the study and equally divided into two groups. After 8 weeks of treatment healing occurred in 31 of 40 patients treated with diltiazem and 33 of 40 patients treated with GTN [p = 0.576]. There were less side-effects with DTZ [n=13] than with GTN [n=29, p < 0.001]. In particular, headache occurred more commonly with GTN [n=27] than with DTZ [n=9, p < 0.0001]. Diltiazem hydrochloride and glyceryl trinitrate were equally effective in healing chronic anal fissure. Diltiazem caused fewer side-effects particularly headache than glyceryl trinitrate ointment. Diltiazem may be the first-line treatment for chemical sphincterotomy for the chronic anal fissure

Vasculopathy in patients with diabetic foot using doppler ultrasound

To determine the extent of vasculopathy in patients with diabetic foot using Doppler ultrasound scanning. This descriptive study was carried out in Surgical Unit III, Civil Hospital, Karachi from January 2004 to December 2005. All patients having diabetic foot complications including abscess formation, cellulitis, ulceration and gangrene were included in the study after taking informed consent. Peripheral pulses like posterior tibial, dorsalis pedis, and popliteal arteries were checked. The presence of vasculopathy was checked with Doppler scanning of dorsalis pedis artery, posterior tibial artery, popliteal artery and veins. The data was collected on a proforma that was specially designed for this study. Out of the total 30 patients included in this study, vasculopathy was detected in 19 [63.33%] patients. The pulse was clinically weak in 10 [33.33%] and absent in 7 [23.33%] patients, while the Doppler scan revealed that in 17 [56.66%] cases the dorsalis pedis artery and in 19 [63.33%] the posterior tibial artery was involved. These findings were asymmetrical i.e. they were mostly found in the affected limb, with a male preponderance. This study shows that the vasculopathy is strong independent risk factor in the development of diabetic foot lesions. The usual symptoms and signs of lower limb ischemia may not be present and indeed may be misleading in diabetic foot disease

Mechanical intestinal obstruction: etiology and management in adults at civil hospital, Karachi

To determine the etiological factors, management and outcome of mechanical intestinal obstruction in adults at Civil Hospital, Karachi. The hospital records of all patients operated on for mechanical intestinal obstruction in Civil Hospital, Karachi, over a period of one year [July 2006 to June 2007] were reviewed. Signs and symptoms with duration, etiology, surgical management, morbidity and mortality, apart from demography, were recorded. Patients were followed until their discharge. A total of 119 patients, 74 male and 45 female, with a mean age [ +/- SD] of 37.29 [ +/- 16.08] years were operated on during the study period. Their mean [ +/- SD] duration of symptoms was 4.1 [ +/- 3.9] days. Obstructed external hernias were the most common cause of intestinal obstruction, seen in 36 [30.2%] patients, followed by intestinal tuberculosis in 24 [20.2%] patients. Stoma formation was the most common surgical procedure performed in 40 [33.6%] patients followed by hernia repair, with or without resection, and anastomosis of bowel in 36 [30.2%] patients. Complications were documented in 34.4% of patients. Mortality was 9.2% during the hospital stay. Obstructed external hernias were the commonest cause of intestinal obstruction followed by intestinal tuberculosis. Stoma formation was the commonest surgical procedure performed. During the first year of surgical training, all residents should master the skills of making an appropriate stoma, while during the second year they should be able to manage obstructed hernias properly