A rare presentation of an acute abdomen: an ileal diverticular perforation.

BACKGROUND: This case report highlights the value of prompt intervention of diagnostic laparoscopy in a patient suspects of having an acute abdomen due to an intestinal perforation, where there is a limitation of performing Contrast Enhanced Computed Tomography of abdomen. A previously healthy young adult presenting with an acute abdomen due to a spontaneous ileal perforation, without any associated risk factors is a rare clinical entity in a developing country. Therefore, entertaining an early diagnosis will possibly prevent a fatal consequence. CASE PRESENTATION: A male patient, 29 years old, recently diagnosed as a young hypertensive without any associated factors, currently on antihypertensive treatment, was admitted to our hospital presenting with an acute severe abdominal pain. During initial assessment, the patient was febrile (101 °F), ill looking, tachycardic (pulse rate 121 bpm) with rapid shallow breathing. Abdominal examination reviled diffuse guarding and rigidity, more severe on right iliac fossa. Following history and clinical examination probable clinical diagnosis was made as an acute appendicitis with perforation. However, ultrasonography was found to have normal appendix. Contrast Enhanced Computed Tomography was not performed as a subsequent investigation because of the impairment of renal functions of this patient. Though, non-contrast CT would have been ascertained more diagnostic yield, given the critically ill status of this patient we decided to perform urgent diagnostic laparoscopy. It reviled pus in several abdominal cavities and dense adhesions. Therefore, the procedure was converted to a laparotomy and found to have an ileal perforation with diffuse peritoneal contamination. Diseased ileal segment was resected and anastomosed. Followed by peritoneal lavage. CONCLUSION: Ileal perforation due to diverticular disease in a healthy young adult is rare. This case report highlights the importance of considering this clinical entity as a differential diagnosis, the value of early diagnostic laparoscopy, especially in clinical settings with limitations to CT scan, since late diagnosis can give rise to fatal outcome.

Endoscopic observations around the gastroesophageal junction in patients with symptomatic gastroesophageal reflux disease in South Asia.

INTRODUCTION: We studied the inter-relationships of endoscopic findings around the gastroesophageal junction in patients with symptomatic gastroesophageal reflux. METHODS: Data were collected with regard to hiatus hernia (HH), columnar-lined esophagus (CLE), reflux esophagitis (RE) and gastroesophageal flap valve (GEFV), prospectively from 1,150 patients who underwent diagnostic upper gastrointestinal endoscopy for symptomatic gastroesophageal reflux. RESULTS: The frequency of HH, CLE and RE was 14.3% (n=165), 9.5% (n=109) and 13.3% (n=153), respectively. In the CLE group, 48 were histologically proven to have Barrett's esophagus. Of all RE patients, 94.8% had mild esophagitis (LA-A and B) and this was associated with younger age, male gender, presence of HH, and grade 3 or 4 gastroesophageal flap valve (GEFV). Grades 3 and 4 GEFV were associated with HH, CLE, and RE. CONCLUSIONS: Substantial proportion of patients with symptoms of GERD has abnormal endoscopic findings around the gastroesophageal junction.

Biliary microlithiasis, sludge, crystals, microcrystallization, and usefulness of assessment of nucleation time.

BACKGROUND: The process of microcrystallization, its sequel and the assessment of nucleation time is ignored. This systematic review aimed to highlight the importance of biliary microlithiasis, sludge, and crystals, and their association with gallstones, unexplained biliary pain, idiopathic pancreatitis, and sphincter of Oddi dysfunction. DATA SOURCES: Three reviewers performed a literature search of the PubMed database. Key words used were "biliary microlithiasis", "biliary sludge", "bile crystals", "cholesterol crystallisation", "bile microscopy", "microcrystal formation of bile", "cholesterol monohydrate crystals", "nucleation time of cholesterol", "gallstone formation", "sphincter of Oddi dysfunction" and "idiopathic pancreatitis". Additional articles were sourced from references within the studies from the PubMed search. RESULTS: We found that biliary microcrystals account for almost all patients with gallstone disease, 7% to 79% with idiopathic pancreatitis, 83% with unexplained biliary pain, and 25% to 60% with altered biliary and pancreatic sphincter function. Overall, the detection of biliary microcrystals in gallstone disease has a sensitivity ranging from 55% to 87% and a specificity of 100%. In idiopathic pancreatitis, the presence of microcrystals ranges from 47% to 90%. A nucleation time less than 10 days in hepatic bile or ultra-filtered gallbladder bile has a specificity of 100% for cholesterol gallstone disease. CONCLUSIONS: Biliary crystals are associated with gallstone disease, idiopathic pancreatitis, sphincter of Oddi dysfunction, unexplained biliary pain, and post-cholecystectomy biliary pain. Pathways of cholesterol super-saturation, crystallisation, and gallstone formation have been described with scientific support. Bile microscopy is a useful method to detect microcrystals and the assessment of nucleation time is a good method of predicting the risk of cholesterol crystallisation.

Microbiology of gallbladder bile in uncomplicated symptomatic cholelithiasis.

BACKGROUND: Few studies have assessed microflora and their antibiotic sensitivity in normal bile and lithogenic bile with different types of gallstones. METHODS: We performed a case control study of 70 bile samples (35 cholesterol and 35 pigment stones from 51 females and 19 males, aged 21-72 years with a median age of 37 years) from patients who underwent laparoscopic cholecystectomy for uncomplicated cholelithiasis, and 20 controls (14 females and 6 males, aged 33-70 years with a median age of 38 years) who underwent laparotomy and had no gallbladder stone shown by ultrasound scan. The bile samples were aerobically cultured to assess microflora and their antibiotic susceptibility. The procedures were undertaken under sterile conditions. RESULTS: Thirty-eight (54%) of the 70 patients with gallstones had bacterial isolates. Nine isolates (26%) were from cholesterol stone-containing bile and 29 isolates (82%) from pigment stone-containing bile (P=0.01, t test). Twenty-eight of these 38 (74%) bile samples were shown positive only after enrichment in brain heart infusion medium (BHI) (P=0.02, t test). The overall bacterial isolates from bile samples revealed E. coli predominantly, followed by P. aeruginosa, Enterococcus spp., Klebsiella spp. and S. epidermidis. There were no bacterial isolates in the bile of controls after either direct inoculation or enrichment in BHI. CONCLUSIONS: Bacterial isolates were found in pigment stone-containing bile. Non-lithogenic bile revealed no bacteria, showing an association between gallstone formation and the presence of bacteria in bile. Antibiotic sensitivity patterns of isolated organisms were similar irrespective of the type of stone.

Assessment of 'nucleation time' as a predictor of cholelithiasis.

INTRODUCTION: In the formation of gallstones, crystal nucleation is a key step, which is followed by precipitation and gradual growth of cholesterol crystals. MATERIALS AND METHODS: A case-control study was carried out among 60 patients (30 patients, 14 males and 16 females, median age of 36 years, range 33-71 years, body mass index (BMI)=25.1+/-0.33 kg/m, who underwent laparoscopic cholecystectomy; 30 control individuals, 15 males and 15 females, median age of 38 years, range 33-70 years, BMI=24.5+/-0.23 kg/m, who underwent laparotomy and who had normal ultrasound scans of the gallbladder and no demonstrable stones). Bile aspirated from the common bile duct was ultrafiltered and anaerobically incubated at 37 degrees C. Incubated bile was examined daily by polarized light microscopy, for appearance of cholesterol crystals. Nucleation time (NT) of bile was assessed as the time taken for the first crystals to appear under polarized light microscopy. RESULTS: Age and BMI of control individuals were not different to those of cases studied. The overall mean NT was significantly shorter in patients versus controls (mean NT+/-SEM: patients, 1.76+/-0.2 days; vs. controls, 12.74+/-0.4 days, P=0.001). Of control individuals, females demonstrated a shorter NT compared with males (mean NT+/-SEM: females, 11.4+/-0.36 days; vs. males, 14.1+/-0.46 days, P=0.006). In contrast, there was no sex difference in NT in patients (mean NT+/-SEM: females, 1.7+/-0.24 days; vs. males, 1.8+/-0.2 days, P=0.7). CONCLUSION: NT in control individuals without gallstones was significantly prolonged compared with the NT in patients with established gallstone disease. Among the control individuals, females had a significantly shorter NT than males. Hence, the assessment of NT is predictor of cholelithiasis.

Hepaticocystic duct and a rare extra-hepatic "cruciate" arterial anastomosis: a case report.

INTRODUCTION: The variations in the morphological characteristics of the extra-hepatic biliary system are interesting. CASE PRESENTATION: During the dissection of cadavers to study the morphological characteristics of the extra-hepatic biliary system, a 46-year-old male cadaver was found to have drainage of the common hepatic duct drains directly into the gall bladder neck. The right and left hepatic ducts were not seen extra-hepatically. Further drainage of the bile away from the gallbladder and into the duodenum was provided by the cystic duct. Formation of the common bile duct by the union of the common hepatic duct and cystic duct was absent. Further more the right hepatic artery was found to be communicating with the left hepatic artery by a "bridging artery" after giving rise to the cystic artery. An accessory hepatic artery originated from the "bridging artery" forming a "cruciate" hepatic arterial anastomosis. CONCLUSION: Combination of a Hepaticocystic duct and an aberrant variation in the extra-hepatic arterial system is extremely rare.