Acute small bowel obstruction due to bilharziasis

Schistosomiasis remains a major world health problem. The disease presents with protean manifestations in the endemic areas. Small bowel schistosomiasis leading to acute intestinal obstruction is an extremely rare clinical presentation. The disease may mimic peritoneal tuberculosis or carcinomatosis intra-operatively. Small bowel bilharziasis leading to obstruction has not been reported in the recent indexed English literature. This report describes a 50-year-old Yemeni male presenting with acute small bowel obstruction due to schistosomiasis. We review the pathological changes in the intestine following schistosomal infection and discuss diagnosis and treatment. We emphasize the importance of histopathology on all surgical specimens

Outcome of nonoperative management of blunt liver trauma

To evaluate our experience with the management of blunt liver trauma at Riyadh Central Hospital, Kingdom of Saudi Arabia. The hospital records of 68 patients treated for blunt liver trauma at Riyadh Medical Complex over a 5-year period [1997 through to 2002] were reviewed retrospectively. Patients who were hemodynamically unstable or had peritonitis were treated by urgent laparotomy [operative group]. The other group of patients were treated conservatively as they were hemodynamically stable [nonoperative group] in the intensive care unit [ICU]. All patients had computed tomogram of the abdomen with oral and intravenous contrast. Injuries grades were classified according to American Association for the Surgery of Trauma [AAST]. Follow up computed tomogram of the abdomen was performed in 1-2 weeks time. A total of 68 patients were treated over a 5-year period. Thirty-three patients [49%] were treated by immediate surgery. Hepatorraphy was performed in 22 patients, non anatomical resection in 3 patients and liver packing in 2 patients to control bleeding. No active bleeding was found in 8 patients. Nonoperative group [n=35, 51%] were managed in the ICU for close monitoring. Surgically treated group had more patients with complex liver injury [30% versus 11%], required more units of blood [3.2 versus 2.1] but had a shorter hospital stay [9 days versus 12 days]. Two patients for nonoperated group develop complications [biloma: one patient, infected hematoma: one patient], the nonoperative treatment failed in one patient who required laparotomy due to rebleeding from grade IV liver injury with failure rate of 3%. The only mortality [one patient] was in the operated group. The nonoperative treatment is a safe and effective method in the management of hemodynamically stable patients with blunt liver trauma. The nonoperative treatment should be the treatment of choice in such patients whenever computed tomogram and ICU facilities are available. However, further studies with larger number of patients are needed to support our results

Primary hyperparathyroidism

The aim of the study is to present the clinical pattern, surgical indication and management of primary hyperparathyroidism in a teaching hospital in the Kingdom of Saudi Arabia [KSA]. The records of patients who underwent surgical treatment for primary hyperparathyroidism at the King Khalid University Hospital, Riyadh, KSA from March 1992 to October 2002 were reviewed for epidemiological data, biochemical, radiological investigation, operative procedures, histopathology result, preoperative localization studies included neck ultrasonogram, neck computerized tomography and thallium-technetium subtraction scan. All patients underwent surgery under general anesthesia and procedures were bilateral, unilateral neck exploration, or minimal invasive parathyroidectomy. A total of 41 patients with diagnosis of primary hyperparathyroidism were reviewed. There were 30 females and 11 males with a mean age of 42 years [range 14-78 years]. The musculoskeletal symptoms were the major symptoms in 30 patients [73%] followed by renal stone in 6 patients [14.6%], peptic ulcer in 2, acute pancreatitis in one, asymptomatic patients accounted for 5% [2 patients] and the thallium-technetium scan has the highest sensitivity rate [89%] among the preoperative localization studies. The histopathological results showed adenoma in 36 cases [87.8%], hyperplasia in 3 cases [7.3%] and no pathology found in 2 cases. Almost all the patients presented with late symptoms and complications of primary hyperparathyroidism, the number of asymptomatic patients, is low due to lack of routine serum calcium check up. Owing to the high sensitivity of thallium-technetium scan and the relatively low incidence of hyperplasia [7.3%], we believe that unilateral neck exploration guided by preoperative scan is a suitable procedure for primary hyperparathyroidism

Outcome of laparoscopic cholecystectomy in acute biliary pancreatitis

To evaluate the efficacy, safety, and timing of laparoscopic cholecystectomy in the management of mild to moderate cases of acute biliary pancreatitis. The medical records of 158 patients admitted to Riyadh Medical Complex, Riyadh, Kingdom of Saudi Arabia [KSA] from July 1998 to December 2001 were retrospectively reviewed. Acute biliary pancreatitis was diagnosed in patients who presented with abdominal pain with serum amylase level 3 times the normal limits in the absence of hypercalcemia or hyperlipidemia and presence of gallstones on ultrasonography. Severity of the disease was assessed using Atlanta Symposium criteria. Preoperative endoscopic retrograde cholangiopancreatography [ERCP] was performed in 106 patients [74.6%] on selective basis. One hundred and eighteen patients underwent laparoscopic cholecystectomy after clinical and biochemical resolution of the attack. Standard 4-ports technique was used. Intraoperative and postoperative morbidity and mortality, and postoperative hospital stay were reported. Laparoscopic cholecystectomy was performed in 118 patients and it was possible in 110 cases [93.2%] after 3-8 days of admission. Preoperative ERCP was performed in 106 patients of mild to moderate acute biliary pancreatitis and common duct stones were retrieved in 19 cases [18%]. The procedure was converted to open in 8 cases [6.7%]. Postoperative complications were nausea and vomiting in 10, atelectasis in 8, chest infection in 3, and prolonged ileus in 2. The wound complication occurred in 4. One patient who had bile leak due to cystic duct stump avulsion at CBD junction was treated by endoscopic sphincterotomy plus stenting and another patient had partial CBD injury repaired primarily over a T-tube. Mean postoperative hospital stay was 2.4 days. One patient died due to uncontrolled arrhythmia and heart failure. Laparoscopic cholecystectomy can be safely performed for mild to moderate acute biliary pancreatitis after clinical and biochemical resolution of the attack during the same admission with acceptable morbidity and mortality rates. This strategy will lead to reducing the recurring acute biliary pancreatitis, number of admissions and hospital stay

Extra adrenal retroperitoneal paraganglioma

We herein report a case of a 45-year-old Saudi lady not diabetic nor hypertensive who presented to the emergency room with a one day history of severe central and lower abdominal pain. On examination, she was hemodynamically stable and abdominal examination showed tenderness in the lower abdomen. Her hematological and biochemical investigations were normal. Computed tomography of the abdomen showed an 8 x 7 cm retroperitoneal mass located at the aortic bifurcation. The patient had exploratory laparotomy and complete excision of the mass. The histopathological study showed a paraganglioma. The patient had an uneventful postoperative period and follow up