Synchronous Primary Adenocarcinoma of Distal Common Bile Duct and Gall bladder.

Synchronous primary cancer of the gall bladder and distal common bile duct is rare. There are only few case reports and case series available of these synchronous cancers. Management of this tumor is individualized in these case reports and series based upon the presentation. We present a case of a patient who had multifocal adenocarcinoma involving distal common bile duct and gall bladder. Keywords: Distal common bile duct cancer; gall bladder cancer; synchronous primary.

Prospective Validation of a Decision Tree Model for Prediction of Severity in Acute Pancreatitis.

BACKGROUND: Early identification of severe acute pancreatitis is important for early stratification, goal directed fluid therapy, rationalizing level of care to improve outcome. Various clinical, laboratory and imaging scoring system has been used to identify severe acute pancreatitis with variable results. Recently a decision tree model was proposed using serum creatinine, serum lactate dehydrogenase and oxygenation index to predict severe acute pancreatitis. This system is easy and usable at our centre. Hence, we conducted the study to validate the decision tree model prospectively. METHODS: Patients admitted with a diagnosis of acute pancreatitis were included in the study. Decision tree model was used to identify patients at high and low risk for severe acute pancreatitis. Sensitivity and specificity were calculated for prediction of the decision tree model. RESULTS: Fifty-three patients were included in the study. Fourty-one (77.4 %) patients with mild acute pancreatitis, five (9.4 %) patients had moderately severe pancreatitis and seven (13.2 %) patients had severe acute pancreatitis. Sensitivity and specificity of decision tree model to predict severity of pancreatitis was 97.83%(95 % CI - 88.47% to 99.94%) and 71.43 % % (95 % CI - 29.04% to 96.33%) respectively with positive and negative predictable value of 95.74 % % (95 % CI - 87.45% to 98.64%) and 83.33 % % (95 % CI - 40.49% to 97.35%) respectively. CONCLUSIONS: Decision tree model with serum creatinine, lactate dehydrogenase, and oxygenation index is an easy and useful tool to predict patients at high risk of developing severe acute pancreatitis.

Appropriateness of Indications of Upper Gastrointestinal Endoscopy and its Association With Positive Finding.

INTRODUCTION: Upper Gastrointestinal Endoscopy is a frequently advised investigation for upper abdominal symptoms. Studies have questioned the appropriateness of indications for upper gastrointestinal endoscopy and have shown that inappropriate indications range from 5% to 49%. The unnecessary upper gastrointestinal endoscopy expose patients to the risk. The number of upper gastrointestinal endoscopy is rising in our region and we assume so is the number of unnecessary upper gastrointestinal endoscopy. With an aim to find out the appropriateness of the indications of upper gastrointestinal endoscopy and compare its association with positive findings, we conducted a cross-sectional descriptive study. METHODS: All patients undergoing diagnostic upper gastrointestinal endoscopy during study period were included in the study. Appropriateness of indications for upper gastrointestinal endoscopy was defined as per American Society for Gastrointestinal Endoscopy criteria as "appropriate" and "inappropriate". Upper gastrointestinal endoscopy findings were classified as "significant" and "insignificant" based on endoscopy findings. The extent of this association between appropriateness of indications and upper gastrointestinal endoscopy findings was expressed as the odds ratio of finding a relevant diagnosis in patients with an ''appropriate'' indication compared with those with an 'inappropriate'' indication. RESULTS: Seventy-nine patients were included in the study. Fifty- two (65.8%) of the indications were considered appropriate as per American Society for Gastrointestinal Endoscopy guidelines. Thirty-three (63.5%) of the appropriate indications has clinically significant finding as compared to seven (25.9%) of inappropriate indication with an odds ratio of 4.962 (95% CI:1.773 - 13.890, P=0.002) which is statistically significant. CONCLUSIONS: Appropriate indications have significantly higher rates of clinically significant findings. Use of guidelines may decrease the number of unnecessary procedures.

Management of Severe Pancreaticoduodenal Injuries.

Severe pancreaticoduodenal injuries are rare and no surgeon and institute get enough number of cases to acquire expertise. Hence, the management of such injuries remains controversial. We report a case of 28 years male who sustained a severe pancreaticoduodenal injury and was managed with emergency pancreaticoduodenectomy with immediate reconstruction. Various approaches have been described in literature with variable outcome. Damage control strategy seems to be most useful approach and major resection should be a part of debridement whenever required. Immediate reconstruction can be carried out safely if patients remain hemodynamically and metabolically stable.

Role of biochemical investigation in prediction of biliary etiology in acute pancreatitis.

INTRODUCTION: Acute pancreatitis is common clinical presentation. Gall stone disease and alcohol consumption are most common etiologies. Detection of biliary etiology is important in order to provide definite management in form of cholecystectomy to prevent further attacks. Sensitivity for abdominal ultrasound to detect cholelithiasis is decreased to 67-87% in presence of acute pancreatitis. Difference in biochemical investigations of acute biliary and non-biliary pancreatitis has been proposed to increase the suspicion of biliary etiology. METHODS: Sixty patients admitted with diagnosis of acute pancreatitis from March 2012 to December 2012 were included in the study. The relation between etiology with age, sex, admission serum amylase and liver function test were evaluated. RESULTS: Out of 60 patients 38 (63.33%) and 22 (36.66%) had biliary and non-biliary etiology respectively. Biliary pancreatitis was more common in females (25 vs. 3). Distribution of severity was comparable between both groups. Biliary pancreatitis group had significantly higher amylase level (3466.42 vs. 1987.5, p 0.003) whereas values of liver function test were higher in biliary pancreatitis though not statistically significant. CONCLUSIONS: A simple, rapid and accurate prediction of biliary etiology of acute pancreatitis can be provided by changes in biochemical parameters.