Evaluation of procalcitonin as a predictor of severity of acute appendicitis

Background: Acute appendicitis is the most common surgical emergency worldwide. The treatment of choice is emergency appendectomy. A delayed diagnosis and hence a delayed treatment increases the complication rate. Despite the best efforts negative appendectomy rate is still high since there is no single best test available to reach the diagnosis.Methods: This was an institutional study conducted at DRPGMC Tanda, comprising of 28 patients and 7 healthy controls. The patients with clinical diagnosis of acute appendicitis were subjected to appendectomy after taking a blood sample for serum procalcitonin and performing an ultrasonogram of abdomen.Results: We observed that mean levels of procalcitonin (PCT) were significantly higher in patients of acute appendicitis in comparison to healthy controls. The range of PCT levels in group 2 i.e., patients with uncomplicated acute appendicitis were from 0.54 to 0.74 ng/ml with mean value of 0.61 ng/ml, whereas in group 3 i.e. patients with complicated acute appendicitis, the range were from 1.14 to 2.56 ng/ml with mean value of 1.62 ng/ml. PCT levels were significantly higher in group 3 as compared to group 1 and group 2 (p<0.0001). In group 2, mean PCT levels were significantly higher in comparison to group 1 (p<0.0001). Statistical analysis of our data shows a cut-off value of procalcitonin to be 0.203 ng/ml. We observed sensitivity and specificity of PCT to be 96% and 100% respectively.Conclusions: This study concludes that levels of serum PCT can be used as a laboratory marker for making a diagnosis of acute appendicitis and also for predicting its severity.

Ultrasonogram in Acute Appendicitis, A Surgeon’s Perspective: Original Article

Introduction: The diagnosis of acute appendicitis has essentially been clinical, but USG abdomen has been said to be highly accurate in diagnosing AA. The surgeon’s perspective may not always be the same. Materialsand methods: Appendectomy data of 106 patients from two hospitals of Kangra region was retrospectively analysed. The data was collected for age, sex, initial pre-operative diagnosis, USG findings, intra-operative findings, Histo-pathological examination (HPE) report, post operative hospital stay. Observations:It revealed a sensitivity of about 54% and specificity of 100% for diagnosing AA with the help of USG abdomen. AA was seen most commonly in males as compared to females. Mean age of presentation was 29.34 +/-14.4 years. Mean hospital stay was 3.68 +/-2.25 days. Most common initial preoperative diagnosis was AA (84%). Most common position of the appendix during surgery was retrocecal (53.7%). HPE report revealed AA in 105 patients. Conclusion:USG abdomen is often falsely assuring, leading to unnecessary delay in effectively managing a patient of AA further leading to increased complications. Only the clinically equivocal cases require further radiological investigations where CECT abdomen is the preferred investigation, but it should be used judiciously.

The Enterolith Causing Jejunal Obstruction, An Unusual Presentation: A Case Report

Enteroliths are a rare cause of intestinal obstruction. Patients can present with repeated episodes of intestinal obstruction as long as an enterolith is able to pass through the gut and then suddenly, they get stuck at the terminal ileum or present with the perforation peritonitis, as may happen in case of a diverticular disease. Here, we report the case of a young male presented to the emergency room with acute intestinal obstruction. During the explorative laparotomy, an enterolith was found stuck inside the proximal jejunum which was removed through an enterotomy. This was an interesting case, as the patient did not have any predisposing factors nor did we find any evidence of other pathologies intraoperatively. Moreover, the enterolith was stuck in jejunum, contrary to the belief that terminal part of the ileum is a most common site for the enteroliths to get stuck.

Internal hernia of the Broad Ligament leading to acute intestinal obstruction: a case report.

Acute intestinal obstruction is a frequently encountered surgical emergency but cases arising from internal herniation through the broad ligament are very rare. We report a case of a middle aged lady with intestinal obstruction due to internal herniation of small bowel through the right side of broad ligament and managing her successfully by timely and immediate surgical intervention.

Diagnostic value of Plain Abdominal Radiograph, Ultrasonography and Clinical impression of the surgeon in acute peritonitis.

Background: Exact pre-operative diagnosis of peritonitis remains challenging despite proper history taking and clinical examination, as well as advancement in new imaging techniques. The objective of this study was to highlight the diagnostic value of radiological investigations and clinical impression of the surgeon in acute peritonitis. Methods: We enrolled 50 patients with clinical features suggestive of acute peritonitis, which required surgery, were included. Evaluation of patients was done by detailed history, clinical examination, plain abdominal radiography, ultrasonography examination and final diagnosis on surgery after stabilizing the patient. Pre-operative diagnosis based on history, clinical examination and radiological investigations was compared with the operative diagnosis based on the operative findings. Results: The age of these patients varied from 5 years to 73 years with the mean age of 40.7 years. The commonest cause of acute peritonitis was perforated duodenal ulcer. Based upon history and examination accurate diagnosis of acute peritonitis with its underlying cause could be made in 94% of patients. Accurate diagnosis of perforated duodenal ulcer peritonitis could be made in 92.59% of cases based on history and clinical findings. Clinically acute appendicitis and perforated appendix was diagnosed with the clinical accuracy of 91.66%. On plain abdominal X-ray in standing position free gas under the right dome of the diaphragm was seen in 64% of the cases. The left lateral decubitus X-ray revealed free gas in peritoneal cavity in 70% cases. In our study with the help of ultrasonography of the abdomen we were able to diagnose 85.71% cases of acute appendicitis and 75% of perforated appendix. Free fluid in the peritoneal cavity on ultrasound of the abdomen was present in 70% of patients. Conclusion: In majority of cases of acute peritonitis, clinical impression of the surgeon plays a vital role in reaching the diagnosis if detailed history and meticulous clinical examination is carried out. However detailed history and meticulous clinical examination and radiological investigations may not be a foolproof diagnostic in all cases of peritonitis and the particular issue is settled on laparotomy.

The Use of Dentascan to Diagnose and Treat Mandibular Premolar with Multiple Canals.

Introduction: For successful endodontic therapy it is vital to have thorough knowledge of morphology of the root canal system and its variations besides proficient aseptic intraoperative condition. Mandibular second premolars are usually single rooted tooth with single root canal system. The incidence of the number of roots and the number of canals varies greatly in the literature. Methods and Results: This case report describes an unusual case of mandibular second premolar with two roots and five root canals. This was confirmed by radiographs, dentascan and dental operating microscope (DOM), and was successfully treated using K files system, guttapercha and AH plus sealer in lateral condensation manner. Conclusion: The clinical significance of this case report is that the precise awareness about the aberrant morphologies of the root canal system can only be appreciated when advanced radiographic techniques, magnification and illumination are used to treat such type of cases.

Platelet Rich Fibrin and Nanocry stalline Hydroxyapatite with Collagen Combination in Treatment of Periapical Lesion: A Novel Clinical Approach.

Aims: To use platelet rich fibrin (PRF), which is an autologous platelet concentrate, along with nanocrystalline hydroxyapatite with collagen for treatment of periapical lesion and negotiation of calcified canal of adjacent tooth. Case Presentation: A 19-year-old female reported to the Department of Conservative Dentistry and Endodontics with chief complaint of pain in maxillary right central incisor. Past dental history revealed trauma which she sustained 10 yrs back in the same region. On intraoral examination, there was a draining sinus, in relation to the apex of 11. Also discolouration and crown fracture was found in relation to 11. Periapical radiograph revealed a large diffused periapical radiolucency in relation to 11 and 12, open apex of 11 and calcified root canal in relation to 12. Technique Used in the Study: A periapical surgery under local anaesthesia was planned in the region of maxillary right anterior region in relation to tooth no 11 and 12. Before surgery calcified canal of tooth no 12 was negotiated. PRF and nanocrystalline hydroxyapatite with collagen combination were placed in bony cavity. Follow up of the case was done for period of 6 months. Discussion: In present case combination of nanocrystalline hydroxyapatite with collagen and PRF is used, as it helps in faster bone regeneration. Graft material is osteoconductive and collagen network provides a better scaffold for clot formation and bone regeneration. Conclusion: The combination of PRF and nanocrystalline hydroxyapatite with collagen has been demonstrated to be an effective approach to induce faster periapical healing in present case with large periapical lesion.