Cystic artery pseudoaneurysm after laparoscopic cholecystectomy presenting as haemobilia: a case report.

Cystic artery pseudoaneurysm which developed following a cholecystectomy and resulting in upper gastrointestinal bleeding is a rare entity, with only three cases described in the literature. We report the case of a 26-year old man who presented with upper gastrointestinal bleeding approximately three months after laparoscopic cholecystectomy. Emergency abdominal angiogram revealed a cystic artery stump pseudoaneurysm, with no evidence of active contrast extravasation. The pseudoaneurysm was coil embolised and the patient had no further bleeding episodes. In this situation an angiogram and embolisation rather than surgery is the preferred mode of management both in terms of diagnosis and treatment. The presence of a dilated cystic artery stump on angiogram following cholecystectomy is an "ominous sign", even in the absence of active extravasation of contrast.

The abdominal cocoon and an effective technique of surgical management.

The Abdominal Cocoon is a very rare cause of small bowel obstruction. It is caused by encapsulation of the small bowel by a fibrous membrane. This tropical disease, seen in young females, has also been reported in males. This is one of the largest series of the Abdominal Cocoon, with five new patients (3 males and 2 females) being reported. The traditional surgical treatment of choice is by lysis of adhesions. All patients in this case series had small bowel intubation done in addition to adhesiolysis. Although small bowel intubation is an established procedure for various causes of recurrent small bowel obstruction, to our knowledge this is the first report of its use in the management of the Abdominal Cocoon. We report our surgical technique in the management of this rare disease.

Carcinoid tumor of common hepatic duct.

Primary carcinoid tumors of the biliary tract are extremely rare. We report a 36-year-old woman with recurrent acute cholangitis who was diagnosed to have a carcinoid in the common hepatic duct, with enlarged local nodes. She underwent local resection. I-131 metaiodobenzyl guanidine (MIBG) scanning postoperatively showed no uptake in the tumor bed.

Surgical presentation of melioidosis in India.

BACKGROUND: Melioidosis, the disease caused by Burkholderia pseudomallei, is common in Southeast Asia. It has also been reported from India, where some investigators feel it is under-diagnosed and under-reported. We report our experience with melioidosis presenting as abscesses at unusual sites. METHODS: All consecutive patients with culture proven B. pseudomallei, who presented to a single surgical unit between 1995 and 1998, were evaluated. RESULTS: Three patients presented with splenic abscesses and one with a soft tissue abscess in the neck. One patient developed septicaemia. All patients responded favourably to ceftazidime and/or co-trimoxazole which was started as soon as the diagnosis was confirmed. CONCLUSION: Melioidosis is under-diagnosed in India, probably due to a low index of suspicion of this disease among clinicians. It should be considered as a possibility when abscesses are encountered at unusual sites. The pus must then be cultured to identify the causative agent.

Duodenal ulcer perforation: have H2 receptor blockers reduced mortality?

Elective surgery for peptic ulcer is becoming rare with the use of more effective medical therapy. However, life threatening complications have not reduced in number. A retrospective study was carried out to compare perforation rates per 10,000 admissions, mortality rates from perforated duodenal ulcers per 10,000 admission and the proportion of patients with perforated duodenal ulcer who died, before and after the introduction of H2 receptor blockers in a large teaching hospital in South India. Perforation rates were not significantly different between the two periods under study. There was a small, but statistically significant (p = 0.047) drop in mortality per 10,000 admissions and a significant drop in proportion of patients with perforated ulcer who died (p = 0.028). Inspite of effective medical therapy, there is a subset of patients with duodenal ulcer who continue to perforate. Efforts should be directed towards identifying this subset and offering them early surgery. Mortality rates have not changed significantly.

Diagnosis and management of gastrointestinal angiodysplasia.

Eighteen patients with gastrointestinal angiodysplasia were seen in a single surgical unit over a period of 8 years. The mean age at onset of symptoms was 33 years. The average duration of symptoms was 54 months (range 2 days-16 years). Three patients had gastric angiodysplasia, two had colonic angiodysplasia, both diagnosed endoscopically preoperatively. The remaining patients required further investigation, which included small bowel enema (SBE), erythrocyte tagged scan (ETC), selective visceral angiography and intraoperative enteroscopy (IOE). SBE was useful but not diagnostic in 3, ETC in 3 and angiography in 5. Four patients required IOE for a diagnosis. Follow up of 17 months is available on all patients. Four had recurrence of symptoms. One required re-exploration and resection of 3 feet of small bowel and right hemicolectomy, another is on hormonal therapy and maintaining normal haemoglobin. Two others are asymptomatic on oral iron therapy.