Nonoperative management of grade IV liver laceration following blunt abdominal trauma complicated with delayed bilioplueral fistula.

The incidence of bile leaks following blunt liver trauma ranges from 0.5% to 21%. Bile leaks could give rise to biliopleural fistula, which can end up causing cholethorax, where a bilious effusion is seen in the pleural cavity. Early recognition of this condition is essential for favorable outcome. We report an unusual case of delayed biliopleural fistula causing cholethorax in a 30-year-old male, presented following blunt abdominal trauma following a motor vehicle collision. Abdominal examination revealed tender right upper quadrant. He was haemodynamically stable following initial resuscitation. Computed tomography of the abdomen revealed American Association for the Surgery of Trauma grade IV liver laceration without active extravasation of contrast, causing a moderate haemoperitoneum. Decision was made to manage the liver injury conservatively. Repeat imaging performed on day 11 due to progressive abdominal distension revealed bilateral pleural effusions and increased amount of abdominal free fluid. Bilateral intercostal tubes and an ultrasound-guided pigtail catheter was inserted to the abdomen. The right-sided intercostal(IC) tube drainage found to be bilious, along with a bilious drainage through the pigtail catheter placed on the peritoneal cavity. Due to persistently high drain output, an endoscopic retrograde cholangiopancreatography performed revealed a contrast leakage at cystic duct. Sphincterotomy was performed and a biliary stent was placed. Patient completely recovered following decompression of biliary system. The unusual presentation of biliopleural fistula requires a good clinical acumen for early diagnosis. Timely endoscopic and interventional radiological management for biliary decompression and drainage are required for a successful outcome.

Delay in diagnosis to treatment and impact on survival of gastric adenocarcinoma in a low income setting without screening facility.

The treatment modality of gastric adenocarcinoma (GCA) depends on the stage of the disease at the clinical presentation. Long delays are probably an unfavorable factor for the patient's prognosis. A prospective longitudinal, study involving 145 consecutive GCA was conducted at the National Hospital of Sri Lanka (NHSL). The overall delay (in weeks) was recorded for each patient and divided into four periods-patient, endoscopy, pathology and treatment. The median and Interquartile Range (IQR) duration of delays were calculated and differences were explored with chi square test and Mann Whitney U test Survival analysis was done with Kaplan Meier technique and Cox regression. The median duration of delays for patient, endoscopy, histology reporting delay, other histology delay (specimen transfer delay and report receipt delay) and treatment were 18 (IQR 14-27), 2 (IQR 2-3), 3 (IQR 2-3), 2 (IQR 1-2) and 6 (IQR 4-8) weeks respectively. Delayed patient presentation to hospital was associated with significant adverse median survival 16 (IQR 11.5-22.5) weeks versus 20 (IQR 16-27.5) weeks, p = 0.004. Delay in initiating treatment was associated with significantly lower median survival 04 (IQR 4-6) weeks versus 06 (IQR 4-8) weeks, p = 0.003. Over 60% of both proximal and distal GCA presented at an advanced radiological stage (stage III/IV). The Kaplan Meier analysis showed that the higher hazard function was associated with a higher tumour stage and undergoing chemotherapy. Age of the patient and the treatment modality were significant predictors of the survival. Patient delay and delay in initiation of definitive treatment are the most important factors that adversely affect the outcomes of GCA. Public health interventions aiming to shorten the patient delay time with proper referral for specialist care would play an important role. Also, it is important to minimize these preventable delays and there should be time limits in producing the histopathology report and to establish online portals of hospital and laboratory information systems for easy access of histology reports in future.

Could quantitative real-time polymerase chain reaction assay serve as an alternative test method to evaluate human epidermal growth factor receptor 2 status of gastric carcinoma in the South Asian setting?

BACKGROUND: Human epidermal growth factor receptor 2 (HER2) protein overexpression and/or HER2 gene amplification are/is linked to a dismal outcome of gastric carcinoma (GCa). Immunohistochemistry (IHC) and fluorescence in situ hybridization (FISH) are key methods to identify patients for HER2 targeted therapy. Drawbacks of both the methods warrant novel tests. Hence, we evaluated the value of quantitative real-time polymerase chain reaction (qPCR) as an alternative test method, relative to IHC to detect HER2 status of GCa and to find relationship between these  results with demographic/clinicopathological data. METHOD: Twenty GCa patients with known IHC HER2 scores were evaluated. qPCR was performed for the HER2 gene and amyloid precursor protein (reference gene) in formalin-fixed paraffin-embedded GCa tissue. Cycle threshold values (Ct) were analyzed using the Pfaffl method to detect HER2 gene amplification. RESULTS: HER2 positivity rates by IHC and qPCR were 20% and 35%, respectively. The sensitivity and specificity of qPCR were 67% and 76%, respectively, relative to IHC. qPCR results were reproducible. The diagnostic consistency between IHC and qPCR (κ = 0.146) was slightly agreeable (0.01 < k < 0.20), with a 65% concordance. Based on McNemar's test, there was no significant difference between the results of the two tests. IHC HER2 protein expression had relationship with the tumor (TNM) stage and Lauren histological type (p < 0.05). Positive HER2 gene expression by qPCR showed relationship with depth of invasion, lymph node involvement, and degree of differentiation (p < 0.05). CONCLUSION: Cost-effective qPCR could serve as an alternative test method for detection of HER2 status of GCa. Both HER2 overexpression by IHC and gene amplification by qPCR are associated with adverse clinicopathological features.

Disease-related knowledge in inflammatory bowel disease: experience of a tertiary care centre in a developing country in South Asia.

INTRODUCTION: Disease-related knowledge plays a critical role in facilitating patients' acceptance of their diagnosis and compliance with active participation in the treatment of inflammatory bowel disease (IBD). The aim of this study was to analyse the deficits in knowledge for future health education programmes. METHODS: A validated questionnaire was used to assess and analyse disease-related knowledge among patients with ulcerative colitis (UC) and Crohn's disease who attended outpatient gastroenterology clinics of a tertiary care hospital in Sri Lanka. RESULTS: There were 184 patients (83 males) with a mean age of 44.5 (range 20-78) years. 83.2 percent of the patients had UC. The mean duration of IBD was 8.17 (range 1-28) years, and 33.7 percent of the patients had IBD for over ten years. The mean Crohn's and Colitis Knowledge questionnaire score was 6.86. The majority (68.5 percent) of the patients were aware that sulfasalazine can be used to reduce exacerbations. There was no statistical difference in disease-related knowledge between genders, but the level of education showed a significant difference. Only 14.1 percent of patients were aware that prolonged IBD is a risk factor for colorectal cancer and that screening for colorectal cancer is important. 9.2 percent of the study population was aware of restorative proctocolectomy. CONCLUSION: There is a lack of knowledge regarding colorectal cancer risk and surgical interventions. There was no significant difference in the knowledge scores between genders but there was a significant association with the educational level.

Delay in the diagnosis of esophageal carcinoma: experience of a single unit from a developing country.

OBJECTIVES: Main objective was to analyze the time delay between the onset of symptoms and the histological diagnosis of esophageal cancer. The subsidiary objective was to analyze the relationship between the time delay and stage of the disease at the time of definitive treatment. STUDY DESIGN, SETTING, AND METHODS: A prospective analysis of patients with esophageal cancer presenting to a single unit over a period of 24 months was performed. Interval from the onset of symptoms to the histological diagnosis and stage at presentation was analyzed. RESULTS: There were 48 patients (male = 26) with a median age of 59.5 (range 43 - 84) years. First symptom was progressive dysphagia in all patients. Subsidiary symptoms were, weight loss in 83.3% (n = 40), abdominal / chest pain in 10 (20.8%), regurgitation in 14 (29.2%), odynophagia in three (6.2%), abdominal discomfort in two (3%), and dyspepsia in two (3%). The mean delay from the appearance of the first symptoms to the end point was 14.9 weeks (range 3 - 37 weeks). Total delay was due to patient delay in 82%, endoscopy delay in 7%, and delay in histological diagnosis in 11%. CONCLUSIONS: As the majority (82%) in our study showed patient delay, a community education program may help in their early presentation to the hospital. However, there is also a notable delay in endoscopy and histology (15%) services, mainly due to a shortage of endoscopy units and qualified histopathologists in the state sector.