Adult intussusception: Is associated bowel gangrene common.

Introduction: Adult intussusception is a rare clinical entity in contrast to pediatric intussusception. Varied and non-specific clinical features, delayed presentation, and lack of awareness among attending surgeons to consider it as differential diagnosis complicates the clinical course of the disease. Methods: A retrospective study was conducted in a tertiary care teaching hospital in north India. Nine adult patients who presented with intussusception over a period of six years were analyzed. Their clinical profile, management and underlying pathology were studied. Results: Five out of nine patients had acute presentation while remaining four presented with subacute/chronic symptoms. Median duration of presentation was 8 days (range 2-180 days). Clinical diagnosis of intussusception was considered in only one patient. Ultrasonography clinched the diagnosis in all four patients who presented with subacute/chronic symptoms. Ileo-ileal intussusception was present in five patients, with one having associated jejunojejunal intussusception. Other four patients had ileo-colic intussusception. Seven of the 9 patients (77%) were found to have associated bowel gangrene. Resection of the bowel segment having intussusception was done in all patients. Five patients had associated benign intestinal pathology while idiopathic intussusception was present in four patients. Conclusion: The patients presented in the series are distinct from cases reported earlier in literature in term of late presentation, manifesting as acute intestinal obstruction, high frequency of associated intestinal gangrene, and absence of associated intestinal malignancy. Patients presenting with features of intestinal obstruction and abdominal lump should be subjected to urgent imaging studies to examine the possibility of intussusception. The high frequency of bowel gangrene encountered in patients of adult intussusception mandates prompt surgical intervention soon after diagnosis.

Plasticobezoar-another new entity for Rapunzel syndrome.

Rapunzel syndrome- a form of trichobezoar occurs when a gastric trichobezoar extends beyond the pylorus into the bowel. We report two cases of Rapunzel syndrome, one of them caused by ingestion of plastic material, so as to name it as a 'Plasticobezoar'. To the best of our knowledge no Rapunzel syndrome due to this material has been reported so far.

Unusual rectal stricture.

The aetiology of rectal stricture is varied, with malignancy being the commonest cause. We report the case of a 26-year-old man, from the state of Bihar, India, who presented with features of large bowel obstruction. Investigations revealed a rectal stricture. Biopsy from the affected site demonstrated non-specific inflammation. An anterior resection was carried out as it was not possible to convincingly rule out malignancy. Histopathological examination of the resected specimen reaffirmed the nonspecific inflammation. This case illustrates that long stricture of rectum my have a benign cause.

Effect of oral glutamine administration on oxidative stress, morbidity and mortality in critically ill surgical patients.

OBJECTIVE: To examine the effect of enteral administration of glutamine in patients with peritonitis or abdominal trauma. METHODS: In a prospective, interventional, observer-blind, randomized clinical trial, 120 patients, aged 18-60 years, were randomized to receive either enteral glutamine 45 g/day for 5 days in addition to standard care (n=63; group A) or standard care alone (n=57; group B). Surgical intervention was done as needed. RESULTS: The two groups were comparable for sex and severity of illness scores. Following treatment, serum malondialdehyde (MDA) levels in group A increased from 4.4 (8.0) to 7.2 (4.8) mmol/mL, whereas those in group B decreased from 3.9 (4.9) to 3.1 (5.0) mmol/mL; these changes were not statistically significant. Reduced glutathione levels increased from 0.03 (0.04) to 0.06 (0.12) mg/g Hb (p=0.032) after treatment in group A and from 0.03 (0.03) to 0.05 (0.04) mg/g Hb (p=0.001) in group B. Infectious complications were equally frequent in the two groups (group A: 44; group B: 37; p=0.571). Survival rate and duration of hospital stay were also comparable in the two groups. CONCLUSION: Enteral glutamine supplementation offers no advantage in patients with peritonitis or abdominal trauma.

Acute appendicitis: a quality assurance study.

The parameters that indicate the quality of patient care in acute appendicits (AA) were evaluated. One hundred sixty-four patients, who underwent emergency appendectomy (EA) at the B.P. Koirala Institute of Health Sciences, Dharan, Nepal were studied prospectively. The mean duration of the symptoms was 42.2 +/- 69.5 hours (range 2-720 hours, median 24 hours). The mean waiting period in the hospital was as 12.7 +/- 21.8 hours (range 1-188 hours, median 7 hours). Special investigations' such ultrasonography, computed tomography or laparoscopy, were not used for diagnosis. The perforation rate was 39%. The histopathology report of 79% of the patients was available. Diagnostic accuracy in histologically evaluated patients was 91.5%. One patient (0.6%) died. The mean hospital stay was 3.2 +/- 2.0 days (range 1-17 days). Patients who had to wait in hospital for < 24 hours before surgery had a longer duration of symptoms, underwent exploratory laparotomy through a mid-line incision more frequently, had a higher incidence of perforated/gangrenous appendix and longer hospital stay. The mean medical expenditure for patients treated in the general ward was Nepali Rupees (NR) 2485 +/- 504 (range NR 1372-4500). The majority of patients/guardians (88%-97%) were satisfied with the medical expenditure incurred, promptness of service, behaviour of the hospital staff and the facilities available in the hospital. The diagnostic accuracy and cost of treatment were favourable. The longer duration of symptoms, non-utilization of special investigations for diagnosis, high perforation rate and less than cent-per cent biopsy rate are the aspects that require attention to improve the quality of surgical care.

Mucinous carcinoma of rectosigmoid in a 15-year-old child: a case report.

A 15-year-old girl with Duke's B mucinous carcinoma of the rectosigmoid was treated with surgical resection and adjuvant chemotherapy. The patient is alive and has been disease-free for 15 months. Colorectal carcinoma is extremely rare in children and adolescents. Adenocarcinoma of colon is a virulent disease in children and has a poor prognosis. This is because of the poor histological characteristics and difficulty in diagnosis.