Fatal ascaris pancreatitis

Gastrointestinal parasites are an uncommon cause of biliary and pancreatic obstruction in the Arabian Gulf; it could have serious complications and even mortality. A Bengali male thirty-two year old patient recently arrived in Bahrain for presented with all the features of acute pancreatitis, no evidence of gallstones or alcohol abuse. He died despite all the therapeutic measures. Endoscopy revealed an Ascaris lumbricoides within the ampulla of Vater. Ascariasis is uncommon cause of acute pancreatitis, which should not be ignored

Pseudo-angiomatous stromal hyperplasia: benign tumor of the breast

Pseudo-angiomatous stromal hyperplasia [PASH] is a rare benign tumor of the breast which poses a clinical challenge in distinguishing it from malignancy. We are reporting a young married woman, who presented to the clinic with right breast painless large lump. The patient was managed surgically. Fine needle aspiration-cytology did not confirm the diagnosis. The final diagnosis was arrived at through histopathology

Fulminant amebic colitis a life threatening rare entity

To present two uncommon cases of Fulminant Amebic Colitis. Retrospective study. Surgical and Medical Department at Salmaniya Medical Complex. From March to September 2008, two cases of fulminant Amebic Colitis were seen and reviewed as far as their presenting features, investigation, characteristic histopathologic picture, and management. Two cases of Amebic Colitis were found in the hospital records during the last ten years. Both presented to the clinic within the last six months. Both patients were males, young, from poor socio-economic class and are originally from Indian subcontinent. Both had vague and mild presentation. One progressed to massive lower GI bleeding and the other one progressed to colonic perforation and peritonitis. The second case had CT scan, which showed signs of colitis and suspected perforation but was not diagnostic of Amebic Colitis. The first case had subtotal colectomy and primary anastomosis; while, the second case had limited colectomy with proximal colostomy and distal mucus fistula. The diagnosis was based on histopathology of the resected specimens. Serology was confirmatory in only one patient. Fulminant Amebic Colitis is a rare entity. Clinical awareness and early surgical intervention are very important in the outcome. Two cases of fulminant Amebic Colitis have been managed by colonic resection of the affected part, in addition to Metronidazole and broad-pectrum antibiotic

Risk factor of breast cancer in Bahrain

Breast cancer is the most common cancer in females worldwide, and the second leading cause of cancer deaths in women. It is accounting for 32% of all cancers. It is well known that gender, age, past history of malignancy, family history of malignancy, prolonged uninterrupted exposure to estrogen are recognized risk factors of breast cancer. Few studies on risk factors in Bahrain were performed. To assess the primary risk factors of breast cancer in patients living in Bahrain. All patients operated by the two senior authors in Salmaniya Medical Complex and Ibn Al-Nafees hospitals in Bahrain. Prospective study. A clinical review of 105 breast cancer patients performed from August 1999 to September 2008. Bahraini and non-Bahraini patients are included. Presentation, diagnostic approach, and management were evaluated. Characteristic data included were age at presentation, age at menarche and menopause. Other factors age at first full term pregnancy, history of lactation, history of using hormonal replacement therapy, history of using oral contraceptive pills, past personal history of malignancy and, type of malignancy, family history of breast cancer. One hundred and five patients, all were females. The age of patients at diagnosis was categorized as follows: less than 35 years old were 10 patients [9.5%], 35-45 years were 33 patients [31.4%], 46-55 years were 30 patients [28.6%] and more than 55 years old were 32 patients [30.5%]. Twenty patients had early menarche [19%], 3 patients [2.8%] had late menopause. Twenty patients were nulliparous [19%]. Six patients [5.7%] had their first delivery at an age of more than 30 years while those who had their first delivery at less than 30 years of age were 79 patients [75.2%]. Lactation history was negative in 27 patients [25.7%]. Twenty-one patients [20%] used Oral Contraceptive Pills [OCP] for long periods. Two patients [1.9%] only were on Hormonal Replacement Therapy [HRT]. Two patients [1.9%] had positive past personal history of malignancy [breast and ovaries]. Twenty-two patients [20.9%] had positive family history of breast cancer. Almost 70% of our patients were below or equal to 55 years at presentation. Family history was found significantly higher in our patients [20.9%]

Fat necrosis following breast - cancer surgery and radiotherapy

Local recurrence is the most devastating complication post breast cancer surgery and radiotherapy. It is difficult to differentiate it from fat necrosis, which has higher incidence. Investigate the incidence of fat necrosis after breast cancer surgery with radiotherapy. Retrospective review study. Surgical department, Salmaniya Medical Centre, Kingdom of Bahrain. Between August 1999 and September 2007, eighty-seven patients of breast cancer patients were diagnosed in our firm. Patients with recurrent masses in the treated breasts or scars were 17. Data was collected mainly from the histopathology department and medical files. It included: the number of patients involved, the stage of the disease, the details of the original surgery and if radiotherapy was administered or not, the method of diagnosing fat necrosis and the method of management. Analysis of these 17 patients showed that their breast mass was diagnosed to be secondary to fat necrosis and radiation changes in 15 and recurrence of malignancy in 2 patients. The diagnosis was reached either by fine needle aspiration cytology or biopsy either true-cut or excisional. The TNM classification of these 15 patients at presentation, was T2 [13 patients], No [9 patients], and all the patients were MO. The original surgery was mainly breast conserving surgery in 10 patients. All patients except one received radiotherapy. These masses were diagnosed after one year. The diagnosis was suspected clinically in 10 patients. In 15 patients, fine needle aspiration cytology was done. True-cut biopsy was needed in two patients. Excisional biopsy was done in 6 patients, one had mastectomy and 8 patients were kept on observation [i.e. regular clinical, radiological and cyto-or histopathological evaluation / 6 weeks-3 months]. Fat necrosis following breast cancer surgery and radiotherapy is a common complication that could be expected more than local recurrence of cancer. Fat necrosis differential diagnosis necessitates improvement in the radiological and pathological investigation to reach the diagnosis and to avoid unnecessary surgery

Extra-gonadal endometriosis: unusual presentation

Extra-gonadal Endometriosis is a rare entity. It is rarely reported from this region. To present six cases of unusual extra-gonadal endometriosis. Retrospective review. Surgical Department, Salmaniya Medical Complex, Kingdom of Bahrain. Six patients with extra-gonadal endometriosis who presented to the surgical department during a period of three years [between 2002 -2005] were reviewed. The patients were females with age ranging between 29 and 48 years. Three patients presented with painful umbilical mass and bleeding during menses. One patient had a painful nodule in her lower segment caesarian section scar; another had endometrioma of the appendix and one presented with acute small bowel obstruction. All had regular menstrual cycle. The majority had associated menorrhagia and dysmenorrhea but did not have any significant past gynecological history. CT scan in three patients confirmed the presence of umbilical nodule or mass but was not helpful in reaching the diagnosis pre-operatively. In the other three cases, pre-operative investigations were not helpful in reaching the definitive diagnosis. The management in all the cases was complete resection. Histopathology confirmed the diagnosis. Six cases of extra-gonadal endometriosis with unusual presentation had been reviewed and presented in this study. Extra-gonadal endometriosis is a rare condition presenting to the general surgeon. Clinical awareness is more important in diagnosis than radiological findings. Complete surgical resection is the rule in all cases

unusual variant of multiple endocrine neoplasia syndrome type IIA

Multiple Endocrine Neoplasia syndrome type IIA typically includes medullary thyroid cancer, pheochromocytoma and/or primary hyperparathyroidism. Other thyroid cancers are uncommonly found with this syndrome. We present a fifty-eight years old female patient with hypercalcemia secondary to primary hyperparathyroidism and an associated non-functioning papillary thyroid carcinoma. The diagnosis was made pre-operatively and the patient underwent resection of parathyroid adenoma and total thyroidectomy. No other endocrine abnormality was detected during follow-up period of five years. We reviewed the association of the two and other endocrine abnormalities

Medical Quiz

A twenty-six year old Indian labourer had arrived in Bahrain since seven days. He presented to accident and emergency department of Salmaniya Medical Complex with a history of abdominal pain in the right iliac fossa, loss of appetite, vomiting and watery loose motions of five days duration. There was no history of passing mucus or blood in the stools. He denied any past history of similar complaints. The patient was afebrile with a pulse rate of 82 per minute. General physical examination was normal. The abdomen felt soft, non-distended with mild tenderness and guarding. Rebound tenderness was also elicited in the right iliac fossa with the possibility of a mass. The liver was not enlarged. Investigations showed haemoglobulin-14.5 g/dl, total leucocyte count is 20.5 X10 9 cells, differential leucocyte count showed polymorphs 76%, lymphocytes 8%, monocytes 14%, band forms 1% and atypical lymphocytes 1%. Liver function tests showed Serum albumin of 29 g/1 and serum globulin of 41 g/1. Total bilirubin was 15 umol/L and mildly raised alkaline phosphatase of 188 u/L. Serum electrolytes showed mild lowering of sodium 136 mmol/L and serum chloride 98 mmol/L. Abdominal ultrasound has suggested the possibility of an appendicular mass. The patient underwent an emergency appendectomy. Peri-operatively, a discrete retrocaecal appendicular mass with thickened peritoneum and meso-appendix was noted. There was no pus found in the mass or the abdominal cavity. Large bowel was unremarkable except for mild thickening of the caecum. The patient did not report during the follow-up period. Pathological findings showed appendix grossly measured 10.5 X 1x 1 cms and looked brownish with exudate on the outer aspect. Histology revealed inflammatory exudate covering patchy areas of ulcerations Ql. What is the histologic finding? Q2. What is your diagnosis? Q3. What is the characteristic finding ? How do you confirm such a diagnosis ? Q4. How do you distinguish Entamoeba histolytica from non-pathogenic Entamoeba coli? Q5. Name the complications of this condition? What are the other abdominal sites where such a pathology can occur?

use of glycery Tri-nitrate ointment in treatment of chronic fissure in ano

Chronic anal fissure is a common painful condition. It is traditionally treated by anal dilatation or by lateral sphincterotomy. However, both of these surgical treatments may cause a degree of incontinence in 35 - 45% of patients. Several recent trials have shown that glyceryl trinitrate [GTN] can reduce sphincter pressure and heal up to 70% of chronic fissures. Assessment of the efficacy of topical 0.2% glyceryl trinitrate [GTN] ointment in the treatment of chronic anal fissure. Prospective uncontrolled clinical study. Surgical polyclinic, Bahrain. Fifty-four patients were diagnosed as having chronic anal fissure and treated with 0.2% GTN ointment during the period from June 2002 to August 2005. They were reviewed at 1, 2, 6-8 and up to 12 weeks to assess symptoms, fissure healing, compliance, duration of symptoms free period after finishing or stopping the course of treatment. At six-eight weeks, the GTN course was completed or taken for longer duration in 34 patients [62.9%]. The course was stopped before 6-8 weeks in 20 patients [37%]. Pain was completely relieved in 25 /34 patients [73.5%] and partially relieved in 5/34 patients [14.7%], bleeding was absent in 32/34 patients [94%], anal tone became normal in 32/34 patients [94%], and 28/34 patients [82.4%] had either healing or healed fissures. Twenty patients stopped GTN course before 6 weeks due to different causes, such as, side effects mainly headache [60%], non compliance [95%], or no response at all [50%]. Recurrence of symptoms in the first six months was seen in 26 patients. There was a highly significant positive relationship between duration of treatment and recurrence of symptoms. The recurrence was treated surgically in 14 patients, traditional ointments in 8 patients, and repeated GTN course in 4 patients. The use of 0.2% GTN induces rapid healing of chronic anal fissures with an 82.4% healing rate in this study. Successful treatment may come at the expense of high incidence of headache although it is lower in our study due to low GTN concentration

Ingestion of a fish bone is a cause of small bowel perforation: a case report and review of the literature

Sixty two-year old Bahraini man presented with history of lower abdominal pain of four hours duration, not associated with fever, vomiting, constipation or diarrhea. Patients had no urinary symptoms, no history of previous medical problems and no past history of previous abdominal surgery. Blood investigation were within normal ranges. Plain erect abdominal radiography showed dilated small bowel loops, no gas fluid levels and no gas under the right diaphragm. Abdominal computed tomography revealed no free intraperitoneal gas and abnormal small bowel loop with thickened wall and mesentery suggestive of inflammation or ischemia. Patient condition was not improving by conservative measures. Laparotomy was performed and a thickened inflamed ileal loop with a fish bone penetrating through its wall was found. There was minimal peritoneal soiling and omentum was coiled around the perforated ileal loop. The fish bone was removed and the perforation was closed. Patients had uneventful postoperative recovery and was discharged on the 12th postoperative day. Retrospectively he mentioned that he had a fish meal three days prior to the abdominal pain