Prevalence and Associated Factors of Diabetic Retinopathy among Type 2 Diabetes Mellitus Patients in Brunei Darussalam: A Cross-sectional Study

Purpose@#To determine the prevalence of diabetic retinopathy (DR) and the factors associated with retinopathy among type 2 diabetes mellitus (DM) patients in Brunei Darussalam. @*Methods@#Cross-sectional study of all type 2 DM patients who attended diabetic eye screening over a 3-month period at one of four government hospitals. We assessed association between DR with the following variables: age, sex, glycated hemoglobin (HbA1c), duration of DM, hypertension, hyperlipidemia, and microalbuminuria. @*Results@#There were 341 patients (female, 58.9%; mean age, 55.3 ± 11.9 years) with a mean duration of DM of 9.4 ± 7.4 years and mean serum HbA1c of 8.4% ± 1.9%. The overall prevalence of any DR was 22.6% (95% confidence interval, 18.8–27.1) with prevalence rates of 4.1% (95% confidence interval, 2.1–6.4) for proliferative DR and 9.7% (95% confidence interval, 6.8–13.2) for vision-threatening DR. Multivariate analysis showed that DR was significantly associated with certain age groups (reduced in older age groups), longer duration of DM (11 years or more), poor control (HbA1c >9.0%) and presence of any microalbuminuria. @*Conclusions@#DR affects one in five patients with DM in Brunei Darussalam, comparable to rates reported for other Asian populations. It is especially worrying that one in ten patients with DM had vision-threatening DR. DR was significantly associated with longer duration of DM, poor control and presence of microalbuminuria but reduced in older age groups. It is important to advocate good control right from the time of diagnosis of DM and institute timely and effective management of retinopathy. DR was significantly associated with longer duration of DM, poor control of diabetes, and presence of microalbuminuria but reduced in older age groups.

Signet ring cell lymphoma of the small bowel: a case report

Gastrointestinal lymphoma of the bowel is uncommon compared to adenocarcinoma. Signet ring cell lymphoma [SRCL] is a rare variant of non-Hodgkin's lymphoma that is characterized by clear cytoplasm with displaced nuclei to the periphery giving a signet ring appearance. Small bowel involvement has not been previously reported. We report the rare case of a 78-year-old female who presented with short history of fever, loss of appetite, nausea, vomiting, mild weight loss with abdominal discomfort and was later diagnosed to have SRCL of the ileum

A Rare Case of Dysphagia Secondary to a Large Oesophageal Lipoma

Dysphagia is considered a warning symptom that requires exclusion of significant pathology such as oesophageal cancer, especially in elderly patients. Benign neoplasms of the oesophagus are rare. We report the case of a 69-year-old lady who presented with a five years history of infrequent intermittent dysphagia that had rapidly progressed over one month. This was associated with globus sensation, weight loss, intermittent episodes of stridor and aspiration pneumonia. Investigations revealed a large oesophageal lipoma in the proximal oesophagus extending down to the lower oesophagus. This was successfully resected via a left cervical approach. She remained well two years after the surgery.

Oesophageal tuberculosis: rare but not to be forgotten

Tuberculosis remains an important cause of morbidity and mortality, especially in underdeveloped and developing nations. Manifestations could be nonspecific and may mimic many other conditions, including malignancies. Oesophageal involvement is surprisingly rare despite the high prevalence of pulmonary tuberculosis and the close proximity of these two structures. We report two cases of oesophageal tuberculosis; a 73-year-old man with simultaneous oesophageal, stomach and duodenal involvement, and a 45-year-old man with isolated oesophageal involvement. Underlying malignancies were initially suspected in both cases, but they were eventually diagnosed as tuberculosis.

Oesophageal ulcers secondary to doxycycline and herpes simplex infection in an immunocompetent patient

Oesophageal ulcerations are generally rare occurrences that are most commonly associated with gastro-oesophageal reflux disorder. Other causes include medications and infections in immunocompromised patients. Among the medications used in daily practice, doxycycline is most commonly implicated. Multiple aetiologies are generally uncommon. We report a case of mid-oesophageal ulcerations secondary to doxycycline and herpes simplex virus infection in an immunocompetent patient.

Tuberculosis: a mimicker of malignancy

Tuberculosis infection remains an important cause of mortality. The clinical and radiological manifestations can be non-specific and resemble many other conditions, including malignancies. This could lead to diagnostic delay. We report the case of a 48-year-old woman with tuberculosis presenting with a right upper lobe mass manifesting as metastatic lung cancer. She also had liver cirrhosis secondary to chronic hepatitis B infection. She developed hepatitis two weeks into her tuberculosis treatment. Our case highlights the importance of considering tuberculosis in patients suspected to have underlying malignancy and to be aware of the potential adverse effects of treatment.

Cholecystectomy rate following endoscopic biliary interventions

Introduction: Gallstones disease is a common disorder and symptomatic disease is usually managed with surgery while those with common bile duct stones are usually managed with endoscopic intervention before proceeding to surgery. This study was intended to assess the rate of cholecystectomy among patients who had undergone ERC interventions, the reasons for not proceeding to cholecystectomy and related complications. Materials and Methods: Patients who had intact gallbladder and had undergone ERC for stones related complications over a two year period were retrospectively identified from the Endoscopic Unit Registry. Detailed case note reviews were conducted. Results: The overall cholecystectomy rate post-ERC interventions was 36.9% (48/130). Cholecystectomy was offered to 59.2% (n=77) and the uptake was only 58.4% (n=45/77). Among those who agreed for cholecystectomy, 11.1% (n=5/45) failed to turn up for their scheduled surgery. Three patients (6.7%) had symptoms recurrence before their scheduled surgery: two subsequently underwent cholecystectomy without ERC intervention and one who was pregnant was managed conservatively with holecystectomy. Among the patients who had declined cholecystectomy, 18.8% (n=6/32) had symptoms recurrence. Four patients required repeat ERC interventions and eventually all had cholecystectomy subsequently. The most common reason for declining cholecystectomy was 'not keen' and already asymptomatic (46.9%, n=15/32). Among patients who were not offerred cholecystectomy (n=53/130), symptoms recurrence occurred in 15.2% (n=7/53). Four patients required repeat ERC interventions and three subsequently underwent cholecystectomy. Conclusions: The cholecystectomy rate remains low after ERC interventions. Recurrence of symptoms necessating re-interventions occurred in patients offerred and not offerred cholecystectomy. The uptake rate should be improved and delay to cholecystectomy should be reduced to avoid symptoms recurrence. Patients not undergoing interventions should be advised regarding symptoms recurrence and should be monitored.

Porcelain gallbladder: The rare end of the spectrum of chronic cholecystitis

Porcelain gallbladder is an uncommon manifestation of chronic cholecystitis. The wall of the gallbladder becomes hard, calcified and brittle with a bluish-white tinge which resembles a porcelain ceramic. This condition is associated with increased risk of malignancy. We report two cases, both female patients (both 56 years old) who were diagnosed with porcelain gallbladder. One presented with a pyogenic liver abscess and the other was diagnosed to have gallbladder carcinoma on the background of porcelain gallbladder with metastases in liver.

Spectrum of endoscopic findings among patients referred for colonoscopy in RIPAS Hospital

Introduction: Colonoscopy is an investigation for the evaluation of lower gastrointestinal symptoms. Just like any other conditions, it is important to be aware of the spectrum of findings so that appropriate referral and decisions can be made. Materials and Methods: Patients (mean age 52.3 ± 15.3 years old with almost equal proportion of genders) referred for colonoscopy in RIPAS Hospital over a five year period (January 2003 to December 2007) were retrospectively identified and studied. Results: The most common indication for colonoscopy was bleeding per rectum (22.9%), followed by evaluation of abdominal pain (18.6%), anaemia (11.7%), colorectal cancer screening (11.7%), evaluation of constipation (5.9%) and altered bowel habits (3.8%). A large proportion (58.4%) colonoscopy was normal. The most common positive finding was haemorrhoids (30.3%), majority of which were categorised as grade I. This was followed by colonic polyps (17.6%), diverticular disease (12.1%), non-specific colitis (4.0%), colorectal cancers (4.0%) and ulcers (3.6%), melanosis coli (0.4%) and telangiectasia (0.1%). Colorectal cancer was most common among the Malays (4.4%), followed by the Chinese (4.0%), the indigenous (2.8%) and the others (1.2%). Conclusions: Our study showed that the most common indication was for the evaluation of bleeding per rectum. Majority had normal colonoscopy and the most common positive finding was haemorrhoids. Importantly colorectal neoplasms accounted for one fifth of procedures with colorectal cancers accounting for four percent.

A patient with dysphagia and iron deficiency anaemia - Answers

(Refer to page 208) Answer: Plummer-Vinson or Patterson-Kelly-Brown Syndrome Plummer-Vinson syndrome (PVS) is defined as a triad of upper oesophageal web (or ring), dysphagia and iron deficiency anaemia (IDA). It was first reported in the early twentieth century, and is also widely known as the Patterson- Kelly-Brown syndrome (PKBS) or sideropenic anaemia with epithelial lesions.

A patient with dysphagia and iron deficiency anaemia

A young lady was evaluated for chronic iron deficiency anaemia and a long history of intermittent dysphagia especially to solids. The dysphagia had been more prominent in the previous few months. There was no history of menorrhagia. Apart from pallor and mild koilonychias, physical examination was unremarkable. She underwent a barium swallow (panel) and an abnormality was detected. What is the diagnosis? Answer: refer to page 236

Spectrum of hepatic disorders encountered in the Hepatology Clinics of RIPAS Hospital

Introduction: In the Southeast Asian region where chronic hepatitis B virus (HBV) infection remains prevalent, HBV related disorders comprise a significant proportion of cases managed by the Hepatology clinics. Additionally, non-alcoholic fatty liver disease (NAFLD) is becoming an increasingly common condition referred to Hepatology clinics for management. We prospectively assessed the spectrum of hepatic disorders managed by the Hepatology clinics in RIPAS hospital, the only tertiary referral centre in Brunei Darussalam. Materials and Methods: All patients seen for hepatic disorders (new referral or follow-up) during a 32 working days period were included in this study. Patients attending for non-hepatic disorders were excluded. Results: During this period, hepatic disorders accounted for 32.2% of the cases managed. The mean age of patients with hepatic disorders was 43.3 ± 12.2 years old with more male patients (65.7%). New referrals accounted for 10%. Overall, 49.6% were positive for HBV, 12% for chronic hepatitis C virus (HCV) infection and 42.1% had evidence of NAFLD. There were overlaps of disorders in 15.5% (12.5% HBV/NAFLD, 2.1% HCV/NAFLD and 1.2% HBV/HCV). Nineteen cases (5.75) had cirrhosis, most commonly associated with HBV and HCV. A quarter were cryptogenic. Patients with NAFLD were significantly heavier than those with HBV, HCV/HBV and the ‘Others’ group. There was also a significant trend for elevated serum alanine aminotransferase among those with NAFLD. Conclusion: Chronic HBV infection is still the most common hepatic disorder encountered in our Hepatology clinics. However, NAFLD is becoming an increasingly more common condition.

Haemoperitoneum secondary to spontaneous rupture of liver tumour

Hepatocellular carcinoma (HCC) is the most common primary tumour of the liver. Cholangiohepatocellular carcinoma (CHC) is less common and is a variant of HCC. There are many similarities with HCC with the exception that CHC tend to be more aggressive. We report a case of a 50-year-old man who was diagnosed with CHC and suddenly deteriorated secondary to hepatic tumour rupture. Despite aggressive supportive care, his condition rapidly deteriorated and died. Autopsy showed ruptured CHC.

Recurrent abdomen pain and tympanic right upper quadrant - Answers

(Refer to page 165) Answer: Chilaiditi’s sign and Chilaiditi’s syndrome Chilaiditi’s sign is defined by the asymptomatic interposition of part of the intestine (commonly the hepatic flexure of the colon) between the right hemi-diaphragm and the liver. It is usually an incidental finding. When symptomatic, it is referred to as the Chilaiditi’s syndrome. Presentations may range from intermittent recurrent mild abdominal pain to acute intestinal volvulus, though the symptoms reported so far have been inconsistent between different patients and can be nonspecific.

Recurrent abdomen pain and tympanic right upper quadrant

A young lady presented with recurrent abdominal distention and pain. Over the past few years, she had been admitted several times with similar complaints. Each time the symptoms settled with conservative management. Abdominal radiography (Panel) on admission is shown above. What does the radiograph show and what is the syndrome ? Answer: refer to page 187 Images of Interest Brunei Int Med J. 2011; 7 (3): 165 Correspondence

Pressure ulcers in the medical wards of RIPAS Hospital: Incidence and risk factors

Introduction: Pressure ulcers are very common, however their incidence varies widely between hospitals. To date there are no published data available for pressure ulcers in Brunei Darussalam. This study was designed to look at the incidence and risk factors of pressure ulcers among medical patients in RIPAS Hospital. Materials and Methods: All medical patients admitted to all five medical wards during the month of May 2010 were included and identified. A proforma based on the European Pressure Ulcer Advisory Panel (EPUAP) model was used and modified to include several factors that may contribute to the risk of developing new pressure ulcers. The proforma was completed by the attending physician during the patient's admission and then subsequently followed up by the parent admitting team until discharge. Results: There were a total of 305 patients (104 male and 201 female) with a mean age of 48.9 ± 20.4 years. There were five patients with pressure ulcers (1.6%), four of which developed during hospital stay and one patient admitted with an ongoing pressure ulcer. All five patients were female, had co-morbidities, were bed-bound and unwell during admission. On comparison to those without pressure ulcers, patients were significantly older, had more co-morbidities, being bed bound, admissions to intensive care unit and had lower serum haemoglobin (p<0.05), albumin (p<0.05) and total protein (p<0.05) on admission. Two patients died during their in-patient stay due to other medical illness. The remaining patients had prolonged hospital stay (over 30 days). Conclusions: The study showed an incidence of 1.6% pressure ulcers among medical patients in RIPAS Hospital. We identified several factors that are significant in increasing patients’ risk of developing pressure ulcers.

Emphysematous Pyelonephritis

Urinary tract infection is very common and in most cases is self limiting even without treatment. However, in some cases, the infection may progress and leads to serious complication requiring admission and treatment. Emphysematous pyelonephritis is a rare but serious complication of urinary tract infection. The symptoms are similar to those seen in pyelonephritis and without radiological imaging; the diagnosis can be missed with serious consequence. In severe cases, nephrectomy may be indicated. We report a case of emphysematous pyelonephritis in a previously well obese 28 year old lady who was successfully managed with intravenous antibiotic. Her underlying risk factor was undiagnosed diabetes mellitus.

Acute acalculous cholecystitis secondary to dengue fever

Patients with dengue fever usually present with typical symptoms such as fever, frontal headache, retro-ocular pain, myalgia, arthralgia, nausea, vomiting, rash, leucopaenia and thrombocytopaenia. However, they can also manifest with atypical symptoms. Acute acalculous cholecystitis is an atypical manifestation of dengue fever. In dengue endemic areas such as Brunei Darussalam, it is imperative that typical and atypical presentations of dengue fever are recognised so that early diagnosis can be made. We report a case of an 18-year-old Malay lady who presented with fever, cough, abdominal pain, and generalised myalgia. She was found to have acute acalculous cholecystitis secondary to dengue fever.

A characteristic rash - Answers

(Refer to page 34) Answer: Dengue fever with Herman’s rash. Dengue presents as classic dengue fever or haemorrhagic dengue. It is caused by Flavivirus, transmitted to humans by the Aedes aegypti mosquito.

A characteristic rash

A 15-year-old girl was admitted to the hospital with a four day history of fever (between 38 to 39oC) and sore throat. There was also recent history of flooding in her town area. On examination, she had bleeding gums, blanching maculopapular rash all over her trunk and petechiae on her arms and legs. Her full blood count on admission showed pancytopenia. Panel A shows a typical rash over her back and Panel B was taken after placing fingers over the rash for a few seconds. What is the diagnosis? Answer: refer to page 56