Capsule endoscopy: is it really helpful in the diagnosis of small bowel diseases?

Objective: to determine the diagnostic yield and safety of capsule endoscopy for small bowel diseases

Introduction: the small bowel evaluation for any pathology has always been a difficult task because both upper GI endoscopy and colonoscopy could not access this area and other radiological tools like barium studies and CT enteroclysis were less sensitive with associated risk of radiation exposure. Only Push enteroscopy could evaluate the small bowel effectively but was laborious and invasive. Capsule endoscopy was introduced in year 2000 and was accepted with great enthusiasm all over the world3. Now, during the past few years it has also been used for the diagnosis of acute gastrointestinal bleeding in emergency departments and results are quite encouraging 5,6. The procedure was introduced at Department of Gastroenterology-Hepatology, Shaikh Zayed Postgraduate Medical Institute, Lahore, Pakistan in year 2009. Since then, it has been regularly used for investigation of small bowel abnormalities

Methods: video Capsule Endoscopy [VCE] using GIVEN Imaging system was performed on 60 patients having various indications like obscure GI bleeding, undiagnosed iron deficiency anemia, abdominal pain and malabsorption. This was a retrospective analytic study carried out at the Department of Gastroenterology-Hepatology, Shaikh Zayed Postgraduate Medical Institute, Lahore, Pakistan from February 2009 to June 2014. Statistical Analysis was done using SPSS version 22

Results: out of 60 patients, 41 [68.33%] were male, 19 [31.67%] were female. Mean age was 52 years with minimum 11 years and maximum of 85 years. No lesion was found on examination in 8.33% [n=5] patients while presence of blood in the gut resulted in poor visualization in 3.33% [n=2] patients. In remaining 88.34% [n=53] patients, the procedure detected various intestinal lesions. Our study detected presence of Angioectasias in 30.0% [n=18], visible vessels in 6.67% [n=4], strictures in 5.0% [n=3], small bowel ulcers in 10.0% [n=6], edema and erosions in 8.33% [n=5], loss of villi in 11.68% [n=7], intestinal worms in 3.33% [n=2], mass lesions in 8.33% [n=5] and Angioectasia with ulcers in 5.0% [n=3] of patients. The diagnosis in 3 patients was further verified by surgical operation, while enteroscopy was done in 2 patients for confirmation. Capsule impaction occurred in 2 patients. All images of Video Capsule Endoscopy [VCE] were of good quality

Conclusion: capsule endoscopy is a safe and effective procedure with a good diagnostic yield and can be used routinely for the diagnosis of small bowel diseases

Treatment of nonunion of long bone fractures with surgical implant generation network nail

To evaluate the efficacy of surgical implant generation network [SIGN] nail in treatment of nonunion of long bone fractures. Descriptive case series. Orthopedics Unit Mercy Teaching Hospital, Peshawar Medical College Peshawar, from June 2009 to December 2011. The study included 50 patients of age 15 year to 70 year of either sex and established nonunion after either surgical or nonsurgical intervention. All patients were managed by reamed SIGN nail and bone graft was performed. The follow up was done for the union. The data was analyzed with SPSS version 14. There were a total 50 patients with 46 [92%] males and 4 [08%] females. Mean age was 34.84 year. Average duration of nonunion was 16.16 months [range 06-48 months]. Among 50 cases tibia was involved in 30 [60%], femur in 16 [32%] and humerus in 4 [08%]. Thirty- eight [76%] cases were operated before SIGN nailing, with 16 [32%] having external fixator, 14 [28%] intramedullary nailing and 8 [16%] DCP. Twelve [24%] cases were managed conservatively. Average follow up was 21.12 [range 6-31] months. Forty-six [92%] cases were united fully in follow up, 2 [4%] were infected, 1[2%] had broken implant and 1[2%] was persistent nonunion case. Results of reamed solid intramedullary nail were good in terms of union and stability

Functional and radiological outcome of percutaneous pinning for fractures of distal radius

To evaluate functional and radiological outcome of close reduction and percutaneous pinning and plaster for fractures of distal radius. This was prospective study was carried out at Department of Orthopedics surgery at Mercy teaching Hospital ,Peshawar Medical College and Hayatabad Medical Complex, Peshawar, KPK, Pakistan from June 2010 to April 2012. It included 50 patients of age more than 15 years with AO type A and C1 and Fernandez type I and III distal radius fracture. After close manipulation and percutaneous K wiring, plaster cast was applied for 6 weeks. Immediate postoperative and at 6th week X ray of wrist taken for measurement of radial height and volar tilt. Subjective satisfaction of every patient according to Saito chart was evaluated after 6 months. Data was analyzed with SPSS v14. Out of 50 patients, 34 [68%] were males and 16 [32%] females. Mean age was 36.46 years [range 17-60 years]. Immediate postoperative radiographs showed that the average radial height was 10.80 mm [range = 8-14 mm] and volar tilt was 4.50 [degree sign] [range = ?411[degree sign]]. At the time of removal of pin-in-plaster and percutaneous K-wires, the average radial height was 10.00 mm [range = 7-13 mm], and the volar tilt was 4.32[degree sign] [range = ?411[degree sign]]. Subjective satisfaction frequency was excellent in 44[88%] cases and good and fair in 6 [12%]. Pin and plaster is good minimal invasive technique for close reduction and its maintenance during healing process with excellent functional outcome

Olecranon fracture

The objective of the study is to assess the clinical and radiological outcome after tension band wiring of olecranon fractures. Descriptive study. Department of Orthopedics and Spine Surgery, Hayatabad Medical Complex Peshawar. July 2007 to June 2010. 29 consecutive patients of either sex with age above 20 years, having olecranon fracture. Fracture osteosynthesis was achieved with the insertion of two parallel 1.8 mm Kirschner wires from the tip of the olecranon and an 18 gauge wire in a figure of eight fashion. Then functional outcome is evaluated with Mayo Elbow Performance scores [MEPS] while radiological outcomes is evaluated with standard radiographs. Out of 20 patients, male were 19[65.5%] while female were 10[34.5%]. Minimum age was 20, maximum 80 and average age was 47.5 years. There were 7[24.1%] patients with type A, 6[20.7%] type B, 9[31%] type C, 6[20.7%] type E and 1[3.4%] with Schatzker type F fracture. Mayo Elbow Performance Score was Excellent in 13 [44.8%], Good in 10[34.5%], Fair in 4[13.6%] and Poor in 2[6.9%] patients. There were 10[34.5%] complications including prominent wire in 3[10.3%], osteoarthritis in 1[3.4%], broken skin in 3[10.3%], irritation of skin in 1[3.4%], erythema in 1[3.4%] and serous discharge in 1[3.4%] patient. There was no non union recorded in this study. Olecranon fractures heal well in most instances achieving recovery of normal function in more than 95% of patients. Functional outcome is dependent on fracture severity, length of immobilization, and patient factors

Postoperative analgesia with tramadol in orthopedic surgery: continuous infusion versus repetitive bolus administration

To compare the effect of infusion of tramadol with repetitive administration of bolus on postoperative pain in orthopedic surgery. Comparative study. Department of Orthopedics and Spine Surgery Hayatabad Medical Complex Peshawar, form October 2009 to April 2010. Patients with American Society of Anesthesia clinical grade I and II, age >18 year scheduled for ambulatory orthopedic and trauma surgery were included. Half of the randomly selected patients were placed in infusion group [Group I] who received an initial intravenous loading dose of 100 mg tramadol followed by an infusion of 12 mg/hour tramadol for 24 hours after recovery from anesthesia; if necessary, repeated bolus of 50 mg tramadol was given. Half of randomly selected patients were in bolus group [Group II].These patients received a placebo infusion instead of tramadol infusion and only received bolus doses of 50 mg on demand. The pain relief was assessed as excellent or good by 78% of group I and 70% of group II patients. In group I, 65% requested only one or no repetitive bolus, compared with 40% in group II, while two or more bolus were demanded by 30% in group I and 60% in group II. The average analgesic consumption after 6 hours was 222 +/- 50 mg tramadol in group I and 200 +/- 50 mg tramadol in group II, respectively. After 24 hours it was 438 +/- 50 mg tramadol in group I and 250 +/- 50 mg tramadol in group II. While the consumption during the first 6 hours was comparable. From then on the consumption in group I increased significantly. Side effects were reported by 30% in both the groups. Continuous infusion is better than bolus in term of easy administration and better pain control throughout postoperative care

Radiographic outcome of adolescent idiopathic scoliosis surgical correction with posterior spinal fusion using pedicle screw and rods fixation

To evaluate the correction of deformity as measured by Cobb's angle with posterior spinal instrumentation and fusion [PSIF], by using rods and pedicle screw along with autologous bone graft in adolescent idiopathic scoliosis [AIS]. Descriptive case series. Department of Orthopaedics and Spine Surgery Postgraduate Medical Institute, Hayatabad Medical Complex Peshawar, from January 2007 to April 2011. Patients of aged more than 10 years of either sex were included in the study. All patients were managed by posterior spinal fusion using pedicular screws and rod and then evaluated by standing anteroposterior and lateral radiographs post operatively. The data was analysed with SPSS version 10. There were a total 18 patients with 14 [77.8%] females and 4 [22.2%] males. Mean age was 17 years [range 13-30 years]. The preoperative Cobb angle was 450 minimum, 1200 maximum [average 700] which was corrected to 50 minimum, 650 maximum and 200 average postoperatively. Total correctness achieved was 250 minimum, 700 maximum and 500 average. Pedicle screw construct can result in better correction and less frequent implant failures in idiopathic scoliosis

Frequency of hepatopulmonary syndrome in cirrhotic patients

To determine the frequency of Hepatopulmonary Syndrome [HPS] in patients with cirrhosis of the liver. Observational cross-sectional study. Department of Gastroenterology and Hepatology, Shaikh Zayed Hospital, Lahore, from April 2005 to March 2006. Fifty consecutive patients admitted with liver cirrhosis were recruited. Twelve patients were excluded due to inadequate echocardiography image quality and inability to perform lung function tests. The diagnosis of cirrhosis was made on clinical, biochemical, serological and metabolic workup, ultrasound abdomen or liver biopsy. Complete blood count, liver function tests, prothrombin time, serum albumin, electrocardiography, chest radiograph, transthoracic contrast echocardiography, arterial blood gas analysis and pulmonary function tests [FEV1] were performed. Results were analyzed as percentages. Chi-square test of proportions and t-test were applied. Total patients evaluated were 38. Mean age was 47.92 +/- 11.38 years, with male [68.4%] to female [31.6%] ratio of 2.1:1. The commonest cause of cirrhosis was hepatitis C [71.1%]. Out of the 38 patients, 11 [28.9%] had HPS including 5 [13.2%] with overt HPS and 6 [15.8%] with subclinical HPS. All patients with HPS had hepatitis C with Child-Pugh- Turcotte [CPT] class C. Factors associated with HPS were digital clubbing, arterial hypoxemia and intrapulmonary vascular dilatations [p=0.02, 0.05 and 0.000 respectively]. In this study, 28.9% patients with cirrhosis of the liver had HPS. All belonged to child class C due to hepatitis C. Digital Clubbing, arterial hypoxemia and intrapulmonary vascular dilatations were important features of hepatopulmonary syndrome