Courvoisier's law revisited

According to Courvoisier's law; if gallbladder is palpable in a jaundiced patient, it is unlikely to be due to gallstones, because stones would have given rise to chronic inflammation and subsequently fibrosis of gallbladder therefore, rendering it incapable of dilatation. Conversely, the causes other than stone [principally tumours], would result in the distension of gallbladder, felt on abdominal palpation. However, in Courvoisier study of 109 cases of dilatation of gallbladder, 17 were due to impacted stones. Therefore, Courvoisier concluded that dilatation of gallbladder was rare with stones obstructing the common bile duct. Despite this fact it is always assumed that the palpable gallbladder is due to malignancy [pancreatic or periampullary etc.]. Here, we report a rare case of palpable gallbladder in a jaundiced patient due to multiple cholelithiasis and a large choledocholithiasis causing obstruction of CBD

Changing trend in topography of peptic ulcer perforation

Objective: to find out the changing trends in topography of peptic ulcer perforation

Design: retrospective

Setting: department of Surgery, Unit II Chandka Medical College Teaching Hospital Larkana

Duration: from July 2004 to June 2007 [3 years]

Patients and methods: the age, sex, clinical presentations, treatment options and operative findings of patients, who presented with perforated peptic ulcer were studied from their case files, and data were analysed

Results: out of 86 patients, 81 were males and 5 were females with a male to female ratio of 16.2:1. The prevalence of perforation was highest in patients of 40-59 years of age. Seventy-six patients underwent emergency explorative laparotomy. Among these, 70 patients had gastric and 6 had duodenal ulcer perforation, resulting in duodenal to gastric ulcer ratio of 1:11.5. Repair with Omentopexy was the procedure employed

Conclusions: peptic ulcer perforation is most common in the stomach of middle aged man

Pattern of firearm injury and outcome

Objective: to study the pattern and outcomes of firearm injuries at Department of Surgery during 3 years

Design: retrospective study

Setting: department of Surgery, Unit II, Chandka Medical College Teaching Hospital Larkana

Duration: three years, from July 2004 to June 2007

Patients and methods: record of all firearm injury cases, who presented during study period, was analyzed. Data were collected on printed proforma from indoor patient record [case file] and operation theatre record. Demographic data, clinical presentation, site and frequency of injuries, investigations including radiology, operative findings, and postoperative course were the variables of study

Results: out of 282 firearm injured patients, 258 were males and 24 were females, with male to female ratio of 10.7:1. The age ranged 12-80 years. Ninety-nine [33.68%] patients had injuries to abdomen only and 72 [25.53%] to chest only, while 72 [25.53%] patients had multiple injuries including injuries to abdomen. One-hundred and twelve [39.71%] patients underwent Laparatomy [including patients with multiple injuries], 66 [23.40%] required chest intubations. Twohundred and forty-four [86.52%] patients were cured and discharged. Seven [2.48%] patients were referred to other departments like Orthopaedic and Neuromedicine and 14 [4.96%] to other hospitals with advanced patient care facilities. Mortality rate was 6%

Conclusion: the firearm injury is common in 20-39 year old males. The most common site of injury is abdomen. The commonly injured intra-abdominal organ is bowel followed by liver and kidney, while most commonly injured extra-abdominal organ is lung

Spectrum of diseases in patients with non-traumatic acute abdomen

Objective: To identify the spectrum of diseases leading to acute abdomen in local population, presenting in a surgical unit. Design: Retrospective study. Setting: Department of Surgery Unit-II Chandka Medical College Teaching Hospital Larkana. Duration: A period of three years, from July 2004 to June 2007

Patients and Methods: All patients presenting with non-traumatic acute abdominal pain were included in the study. Patients presenting with gynecological and urological causes were excluded. Their presentation, diagnosis and management were recorded from their case files and OT registers

Results: During the period under review, a total of 586 patients presented with non-traumatic acute abdomen; of which there were 412 [70.30%] males and 174 [29.69%] females, with a male to female ratio of 2.3:1. The highest incidence of acute abdomen 163 [27.81%] was found in patients of 21-30 years age group, followed by under 20 age group 150 [25.59%] and 30-40 years age group 101 [17.23%]. The most common cause of acute abdomen was acute appendicitis accounting for 205 [35%] admissions. These patients were mostly young males in teens and twenties. Intestinal obstruction was second leading cause accounting for 167 [28.5%] cases and this affected more commonly the middle aged persons. Five hundred and twelve [87.37%] patients were treated successfully and discharged home while 3% left against medical advice. Mortality was 9.55% and it was highest in patients presenting with perforation peritonitis

Conclusion: The most common cause of acute abdomen in this study was acute appendicitis affecting young population. This was followed by intestinal obstruction and gut perforation. Acute cholecystitis commonly affects the middle aged, post-menopausal women. Pancreatitis is a rare cause of acute abdomen in this area