Blood changes after splenectomy in portal hypertension. The "Amna model"

Splenectomy is a frequently performed operation for patients with portal hypertension and hypersplenism in areas endemic for schistosomiasis. Reactive thrombocytosis [RT] has been described following splenectomy. Nevertheless, data are lacking on the long term changes of platelet count and other blood cells and indices after splenectomy in such patients. To determine the hematological changes following splenectomy in portal hypertension due to schistosomiasis. This is a prospective, observational, case study in which we did a series of full blood counts before and after splenectomy on two patients. The periods of study were 12 days and 5 months, respectively. Platelets [RT>500x10[9]] occurred after the 7[th] post-splenectomy day in both patients. In the longer study, RT continued from day 8 to week10. Extreme thrombocytosis [> 1000x 10[9]] occurred from day 11 to day 21 postoperatively. The count was back to normal by week 17. Reactive leukocytosis occurred immediately after ligation of the splenic artery, but returned to normal levels during the 2[nd] postoperative week. Erythrocytes, however, showed changes different from both platelets and leukocytes. There was "persistent anaemia" for about one month postoperatively. This study provides data that were lacking on the long term haematological effects of splenectomy in Sudanese patients with portal hypertension. Knowing these changes can have important implications on the management and follow up of such patients, and provide evidence needed for discussing guidelines of treatment. RT and leukocytosis occur after splenectomy whereas anaemia persists. RT can reach extreme levels and it is wise to monitor the platelets after the discharge of patients from the hospital. It may also be wise to consider the use of antiplatelet drugs postoperatively till the count normalizes. The persistent anaemia, however, seems to correct itself without giving haematinics or blood transfusion.

Use of computer-based clinical examination for assessment of medical students in surgery

The Video-projected Structured Clinical Examination [ViPSCE] replaced the oral [viva] examination as a student assessment tool in clinical surgery in our department since its invention in 2001 [1, 2]. It has been useful for assessing higher knowledge domain including problem-solving abilities. To improve the viewing of the Video-projected Structured Clinical Examination [ViPSCE], we developed a computerized version, and called it Computerized Clinical Examination or [CCE]. This was used to assess medical students' higher knowledge and problem solving skills in surgery. We present how we did it, test scores descriptive statistics, and the students' evaluation. To our knowledge the use of computers in this way has not been reported before. A computer-based clinical examination [CCE] in surgery is administered to assess a class of 43 final year medical students at the end of their surgical clerkship. Like the ViPSCE, the exam was delivered as a slide show, using PowerPoint computer program. However, instead of projecting it onto a screen with a video-projector, each student had his/her own computer. The CCE consisted of 20 slides containing either still photos or short video clips of clinical situations in surgery. The students answered by hand writing on the exam papers. At the end, they filled evaluation forms. The exam papers were corrected manually. The test scores descriptive statistics were calculated, and correlated with the students' scores in other exams in surgery. The evaluation forms were analyzed. Administration of the CCE was straightforward. The test scores were normally distributed. They correlated significantly with the scores obtained by the students in the other exams in surgery. Students' acceptability was high. CCE is feasible. It inherits the validity and reliability of the ViPSCE with the added advantage of improving the viewing of the slides. It proved popular with the students

study of patients with community acquired abscesses at Khartoum north teaching Hospital

Abscess incision and drainage [I and D] operation represents the bulk of surgical procedures in the emergency department [ED]. Nevertheless, epidemiological, clinical, and bacteriology data are lacking or non-existent on patients with abscesses. Information is also lacking on the magnitude of the problem of community acquired methicillin-resistant Staphylococcus aureus [CA-MRSA], and their susceptibility to the most commonly used antibiotics. To identify and document epidemiological and clinical variables of patients with superficial abscesses, and isolate the causative organism [s] in the pus and determine their antibiotic susceptibility. Also, to determine the prevalence of CA-MRSA and their antibiotic susceptibility and ao audit our practice of I and D of abscess. A prospective observational study, involving a convenience sample of patients who presented with community acquired skin and soft tissue [superficial] abscesses to a single unit at Khartoum North Teaching Hospital [KNTH] emergency department [ED], was done during the period 2009-2010.A pro-forma was designed to record the personal, epidemiological, and clinical data of each patient. The I and D of the abscesses was performed as a day case. Swabs of pus drained from the abscess were sent to the laboratory for culture. Micro-organisms isolates underwent susceptibility testing against a group of the most commonly used antibiotics. A total of 248 patients were included in the study. The majority [84%] were below the age of 40 years. Males [69%] were twice as many as females [31%]. The majority of patients did not have a known predisposing factor, but 13% had a previous history of an abscess. A history of trauma was found in 27% of the patients, whereas diabetes mellitus history was obtained in only 6%. The most common site of the abscess was the upper limb [46%] followed by the lower limb [20%]. The study showed that 85% of the abscesses were drained under local anaesthesia. Susceptibility tests were performed on 151 pus specimens using a group of commonly used antibiotics. 123 [81.5%] specimens grew micro-organisms. Of those, Staphylococcus aureus was the commonest organism grown [90%], followed by Klebsiella spp [6.5%]. The proportion of CAMRSA was 24%. High proportions of S. aureus were resistant to other antibiotics too. Lists of antibiotics and their efficacy in the treatment of S. aureus and Klebsiella were constructed. This study documents some epidemiological and bacteriological data on one of the most common surgical problems. The study showed the presence of a significant proportion of CAMRSA. This reflects the abuse of antibiotics in the community and stresses the importance of health education. Standardized surgical and anaesthetic guidelines on I and D of abscess should be followed to avoid recurrences. Further studies are urgently needed

Geophagia: a rare cause of Intestinal Obstruction

We report a 4-year-old male child, who presented with abdominal distension and absolute constipation for 4 days. The mother revealed that her child had been picking up sand and eating it for about a month prior to admission. The child was blind since birth and suffered from cerebral palsy and developmental retardation. Abdominal examination revealed a grossly distended abdomen, but no tenderness or guarding. The abdominal swelling had a doughy feel that was dull on percussion. Rectal digital examination revealed a solid sandy mass. Plain abdominal x-ray showed opacifications in both the large and small bowels. A diagnosis of intestinal obstruction due to geophagia was made. The patient was treated conservatively including rectal washouts. The obstruction was relieved and he started to pass normal stools on the 7th day. We discuss this rare case of intestinal obstruction due to geophagia. We review this feeding abnormality. We describe our management including our novel and simple rectal washout technique. The problems that occurred during the course of the treatment and the role of multidisciplinary approach are highlighted

Small bowel obstruction caused by a carcinoid tumour

We present a rare case of carcinoid tumour presenting as a small bowel obstruction in a young male patient. Pitfalls of diagnosis, including confusion with irritable bowel syndrome are high-lighted. The current management strategies of this tumour are reviewed

Emergency operations for bleeding duodenal ulcer: a simple option to consider: Case report

We report a 46 years-old man who had severe bleeding from a posterior duodenal ulcer [DU] that was diagnosed but could not be treated endoscopically in another health facility. He went into shock as he was being admitted to the casualty at Khartoum North Teaching Hospital [KNTH]. His haemoglobin [Hb] dropped to five gram/dl. He required resuscitation and transfusion of six units of blood overnight. Emergency surgery was performed. Over sewing [OS] of the ulcer was done and the stenosed first part of duodenum was closed transversely [pyloroplasty]. No acid-reducing procedure [ARP] was done. The patient received anti- helicobacter therapy via the intravenous route preoperatively and continued postoperatively. This was later given orally after he started taking by mouth. He made an uneventful recovery with no recurrence of bleeding and was discharged home one week latter. Endoscopy was done at KNTH six weeks later. This showed complete healing of the ulcer with no evidence of Helicobacter pylori in the biopsies taken. We found simple OS of the bleeding DU together with anti-helicobacter therapy safe, efficient, and not associated with re-bleeding. We discuss the rationale of this simple treatment. We propose the need for a randomized controlled study comparing it with acid-reducing procedure [ARP] as options in the surgical treatment of bleeding DU