Strangulated obturator hernia - an unusual presentation of intestinal obstruction

An 81-year-old Caucasian emaciated female presented with 3 days history of colicky abdominal pain nausea, projectile vomiting and abdominal distension. A pre-operative diagnosis of mechanical bowel obstruction was made. The absence of characteristic clinical signs in this thin elderly woman with a small bowel obstruction failed to provide a pre-operative diagnosis. She underwent a midline laparotomy and resection and anastomosis of small bowel and repair of the strangulated right obturator hernia. The high mortality rate associated with this type of abdominal hernias requires a high index of suspicion to facilitate rapid diagnosis and prompt surgical intervention if the survival rate is to be improved

Amoebic liver abscess; needle aspiration after 96 hours of medical treatment

Amoebic Liver Abscess [ALA] is a serious problem in Pakistan Its management includes antimicrobial drugs, needle aspiration and surgical drainage. To determine if amoebic liver abscess can be treated conservatively or requires needle aspiration as well in selected cases. A prospective hospital based study. Nishtar Hospital Multan. 18 months. Thirty six consecutive adult patients with a right lobe liver abscess were included. All patients received metronidazole 800mg orally for 10-14 days and were clinically observed. Patients who did not show any clinical improvement in 96 hours had an ultrasound guided needle aspiration performed. Patients having an ALA less than 10cm in size respond to medical treatment. If patients continue to have toxic symptoms, needle aspiration should be performed. Most patients having ALA of >10cm will end up having a needle aspiration but should be given a trial of medical management

Chronic anal fissure; a randomised, double blind, placebo controlled trial of 0.5% glyceryl trinitrate ointment

Topical application of glyceryl trinitrate [GTN] ointment heals anal fissures, providing an alternative to the traditional first line treatment of surgical sphincterotomy. Tathlith General Hospital Saudi Arabia. January 2001 -April 2003. To determine the effectiveness and safety of topical 0.5% glyceryl trinitrate [GTN] in the management of chronic anal fissure. Individual Patients were randomized to receive 0.5%GTN paste or placebo three times per day for six weeks in addition to oral senna and/or lactulose. Patients took laxatives alone for further 6 weeks. Patients were followed every week for six weeks and then fortnightly for another six weeks to assess pain scores and were given advice. Fifty patients were recruited in this study and 44 patients completed the trial [23 in the GTN group and 21 in the placebo group], patients who could not complete the study were excluded. At 6 weeks, 74% of patients had no pain in the GTN group as compared to the 29% in the placebo group. In 26% of cases treatment was unsuccessful. At three month follow up there was no early recurrence. The prevalence of headaches was 65% in GTN group [reported by 15 patients] and 24% in placebo group [reported by 5 patients]. Mean pain scores were lower in the GTN group as compared to the placebo group. The use of 0.5% GTN induces healing of chronic anal fissures and may be used as a first line of treatment in patients with chronic anal fissure. Successful treatment may come at the expense of a high incidence of headaches