Intestinal obstruction caused by a laxative drug (Psyllium): A case report and review of the literature.

INTRODUCTION: Psyllium in granular dosage form is used as an over - the counter safe laxative drug. It has a considerable hygroscopic propriety which allows it to retain water and expands rapidly to become many times of its original size. PRESENTATION OF THE CASE: 21-year-old man presented to the Emergency Department complaining of lower abdominal pain and constipation for five days. He was discharged home on Psyllium for treatment of the constipation. Two days later, he returned to the Emergency Department complaining of increased abdominal distension without passing any stools. The patient was diagnosed to have an incomplete intestinal obstruction resulting from ingesting Psyllium husks without adequate amount of fluids. The patient was treated conservatively. DISCUSSION: Psyllium has a reputation of being safe and effective medication for patients suffering from chronic constipation, especially in elderly. The patient who ingested Psyllium husks as a herbal medication did not receive adequate amount of fluids. Consequently, he developed intestinal obstruction. Similar cases have been reported in the English literature including cases of esophageal obstruction in elderly patients and following gastric banding operations. Furthermore, Psyllium administration with oral contrast in computed tomography enterography may precipitate bowel obstruction in the presence of organic obstruction or post-operative ileus. CONCLUSION: Psyllium can worsen the constipation if not taken appropriately. It is important to instruct patients who are receiving psyllium ingredients to drink a good amount of fluids to avoid the development of bowel obstruction especially in long-term use of such laxatives.

Management of computed tomography-detected pneumothorax in patients with blunt trauma: experience from a community-based hospital.

INTRODUCTION: Diagnoses of pneumothorax, especially occult pneumothorax, have increased as the use of computed tomography (CT) for imaging trauma patients becomes near-routine. However, the need for chest tube insertion remains controversial. We aimed to study the management of pneumothorax detected on CT among patients with blunt trauma, including the decision for tube thoracostomy, in a community-based hospital. METHODS: Chest CT scans of patients with blunt trauma treated at Al Rahba Hospital, Abu Dhabi, United Arab Emirates, from October 2010 to October 2014 were retrospectively studied. Variables studied included demography, mechanism of injury, endotracheal intubation, pneumothorax volume, chest tube insertion, Injury Severity Score, hospital length of stay and mortality. RESULTS: CT was performed in 703 patients with blunt trauma. Overall, pneumothorax was detected on CT for 74 (10.5%) patients. Among the 65 patients for whom pneumothorax was detected before chest tube insertion, 25 (38.5%) needed chest tube insertion, while 40 (61.5%) did not. Backward stepwise likelihood regression showed that independent factors that significantly predicted chest tube insertion were endotracheal intubation (p = 0.01), non-United Arab Emirates nationality (p = 0.01) and pneumothorax volume (p = 0.03). The receiver operating characteristic curve showed that the best pneumothorax volume that predicted chest tube insertion was 30 mL. CONCLUSION: Chest tube was inserted in less than half of the patients with blunt trauma for whom pneumothorax was detected on CT. Pneumothorax volume should be considered in decision-making regarding chest tube insertion. Conservative treatment may be sufficient for pneumothorax of volume < 30 mL.

A rare case of first-trimester ruptured bicornuate uterus in a primigravida.

INTRODUCTION: Bicornuate uterus (BU) is a rare uterine anomaly result from incomplete fusion of the two Müllerian ducts during embryogenesis. BU very rarely can lead to rupture of the uterus during the early pregnancy with high mortality and morbidity rates. PRESENTATION OF CASE: A primigravida in the first trimester (9 weeks) presented complaining of epigastric pain and vomiting for one day. Ultrasound scan was performed at the 7th week of pregnancy and showed a BU with single intrauterine gestational sac in the right horn. On presentation, the patient was pale and irritable. Urgent ultrasound scan showed viable fetus in the right horn, free fluids in Morrison's pouch. Laparotomy showed BU with pregnancy in the ruptured right horn. The defect in the uterus was repaired. Postoperatively, the patient was advised to use contraceptive pills for one year. DISCUSSION: Our patient has a sonographic diagnosis of BU at the 7th gestational week. At that stage, nothing was done except close follow up of the pregnancy. When she developed severe epigastric pain, initially, we thought of peptic ulcer disease complications. Even after deterioration of the patients' condition, the diagnosis was not clear as the urgent ultrasound showed a viable fetus. Blood and fluid replacement therapy, and exploratory laparotomy were essential to save the patient's life. CONCLUSION: This case highlights the fact that uterine rupture can occur in early pregnancy when associated with uterine anomaly. Early sonographic diagnosis has a major contribution in evaluation and management.

Usefulness of free intraperitoneal air detected by CT scan in diagnosing bowel perforation in blunt trauma: experience from a community-based hospital.

INTRODUCTION: Computed tomography (CT) scan has increasingly become the diagnostic modality of choice for the evaluation of patients with blunt abdominal trauma. CT scan is highly sensitive in the detection of small amounts of free intraperitoneal air (FIA). We aimed to evaluate the usefulness of FIA detected by CT scan in diagnosing bowel perforation in blunt trauma patients. PATIENTS AND METHODS: All abdominal CT scans of blunt trauma patients who were treated at Al Rahba Hospital during the period from October 2010 till December 2013 were retrospectively reviewed. The results of abdominal CT scan were compared with the clinical follow up and operative findings to evaluate the sensitivity, specificity, predictive values, and usefulness index of CT-detected FIA in diagnosing bowel perforation. RESULTS: Abdominal CT scans were performed for 419 trauma patients. 21 (5%) patients were found to have FIA, two of them were true positive (10%), six (29%) needed mechanical ventilation, and eleven (52%) had a pneumothorax. 15/21 (71%) patients had multiple FIA pockets; the median (range) was 3 (2-10) air pockets. Two patients with multiple air pockets of 10mm-thick cuts or more had small bowel perforation. Six (29%) patients had a single air pocket of less than 10mm and none had bowel perforation. 398 patients had negative CT scan for FIA; two of them were false negative. CT-detected FIA scan had a sensitivity of 50% (95% CI: 6.8%-93.2%), specificity of 95.4% (95% CI: 92.9%-97.2%.), a positive predictive value of 9.5% (95% CI: 1.2%-30.4%) and a negative predictive value of 99.5% (95% CI: 98.2%-99.9%) for detecting bowel perforation. The usefulness index for abdominal CT scan FIA for detecting bowel perforation was 0.23 (not useful). CONCLUSIONS: Our study which stemmed from a community-based hospital showed that free intraperitoneal air found on abdominal CT scan of blunt trauma patients was an unreliable radiological finding for bowel perforation. The decision for laparotomy should be based on combined clinical and radiological findings. Conservative management with active observation may avoid unnecessary laparotomy.

An unusual stab wound to the buttock.

Stab wounds to the buttock are uncommon injuries that are rarely seen in surgical civilian practice. Although, the wound appears trivial, it may cause major life-threatening visceral and vascular injuries. Failure to detect these injuries may lead to serious morbidity and mortality. Herein, we report a patient with a single gluteal stab wound, which was initially sutured and treated conservatively. Two days later, patient developed fever, lower abdominal pain and tenderness with leakage of fecal material from the wound. Exploratory laparotomy revealed an extraperitoneal rectal perforation for which a Hartmann's procedure was performed. Computed tomography scanning is recommended as a diagnostic tool for stable patients having buttock stab wounds. Diverging colostomy is the standard surgical procedure for extraperitonal rectal injuries that cannot be properly visualized and repaired during a laparotomy. More evidence is needed to assess the fecal non-diversion approach in the treatment of these patients.

Camel-related injuries: prospective study of 212 patients.

BACKGROUND: Camel-related injuries have been less well studied than other animal-related injuries. We aimed to study prospectively the incidence, mechanism, distribution of injury, and outcome of patients admitted to hospital with camel-related injuries in Al-Ain, United Arab Emirates. METHODS: All patients who were admitted to Al-Ain Hospital with a camel-related injury were prospectively studied during the period of October 2001 to January 2010. Patient's demography, time of injury, mechanism of injury, and distribution and severity of injury were studied. RESULTS: A total of 212 patients, all male, with a median age of 28 years (5-89 years) were studied. The estimated incidence of hospitalized camel-related injured patients in Al-Ain City was 6.88 per 100,000 population per year. Camel kicks were most common (36.8 %) followed by a fall from a camel (26.4 %) and camel bites (25.0 %). Camel kicks and falling from a camel were more common during the hot month of August, and camel bites were more common during the rutting season (November to February). Patients with a kick-related injury had a significantly higher rate of maxillofacial fractures compared with other mechanisms. Spinal injuries occurred significantly more often in vehicle occupants who collided with camels compared with other mechanisms (3/7 compared with 7/205, p = 0.0022, Fisher's exact test). Twelve patients (5.7 %) were admitted to the intensive care unit. The mean hospital stay was 8.6 days (1-103 days). Two patients died (overall mortality 1 %). CONCLUSIONS: Understanding the biomechanisms and patterns of injury and correlating them with the behavior of the camel is important for identification and prevention of camel-related injuries.

Camel bite injuries in United Arab Emirates: a 6 year prospective study.

PURPOSE: To prospectively study the incidence, mechanism, distribution of injury, and outcome of patients admitted to Al-Ain Hospital with camel bite injuries in Al-Ain, United Arab Emirates. METHODOLOGY: All patients admitted to Al-Ain Hospital with a camel bite were prospectively studied during the period of October 2001-October 2007. Patient's demography, mechanism of injury including behaviour of the camel, distribution and severity of injury, and outcome were studied. RESULTS: 33 patients were studied having a median (range) age of 27 (10-58), all were males. 97% were from the Indian subcontinent. A majority of injuries (73%) occurred during the camel rutting season (November-March). Twenty-five patients were camel caregivers whilst five were camel jockeys. All camel jockeys were children. Seven patients were raised up by the camel's mouth and thrown to the ground whilst 26 patients were only bitten. Most injuries were in the upper limb (64%) and head and face (15%). 48% of upper limb injuries had associated fractures. Two patients who were bitten at the neck were admitted to the ICU. One of these died due to massive left-brain infarction and the other had complete quadriplegia due to spinal cord injury. The median hospital stay was 6 days. There was only one death (3%). CONCLUSION: The behaviour of the camel is occasionally unpredictable, especially during the rutting season. The mechanism of camel bite injuries, which are usually severe, are complex including penetrating and crushing injuries by the camel jaw and blunt injuries when patients are picked up and thrown away. Care should be taken when handling camels, particularly in the rut.

Motor vehicle collisions with large animals.

Motor vehicle collisions MVC with large animals are a worldwide problem. In this review, we aim to analyze the mechanisms and patterns of human injuries caused by MVC with large animals and various ways to prevent them. Reported studies on large animals that can cause such accidents include the moose, camels, deer, and kangaroos. The moose causes a typical rear-and downward deformity of the roof of the car. The camel falls on the roof of the car causing cervical and head injury to the occupants. Injuries caused by kangaroos and deer are usually mild. Injuries may be caused by direct collision with the animal or hitting another object when trying to avoid it. Alarming signs, underpasses or overpasses for animals, and reflectors that frighten the animals were all used to prevent the collisions. Roo-bars are used in Australia to reduce the car damage when hit by a kangaroo. Fencing has proven useful in United Arab Emirates. The mechanism of injury varies with the size and height of the animal and can be serious. Increased awareness of the effects of collision with large animals and ways to reduce it has to be promoted.

Stromal sarcoma of the breast: a case report.

We report a case of a 36-year-old lady who presented with a huge fungating tumour that involved the entire right breast. The tumour was diagnosed histologically as undifferentiated primary stromal tumour of the breast with axillary lymph node metastasis. We review the literature of this rare malignant tumour. Stromal sarcomas of the breast lack epithelial participation, and diagnosis of these tumours can be difficult. Genome-wide expression profiling is currently used to determine the cell of origin of most sarcomas. Surgery offers the best therapeutic option. Adjuvant radiotherapy is not very beneficial, while chemotherapy has, to date, no established role in the management of this disease. The prognosis is dismal for patients with lymph node involvement. The size of the tumour has a lesser bearing on outcome.

Superior mesenteric vein thrombosis complicating appendicular masses.

Mesenteric vein thrombosis (MVT) is rare. Its diagnosis is usually difficult and delayed. Herein, we report 2 patients who developed MVT as a complication of an appendicular mass. One of them had appendectomy and developed fever 10 days postoperatively. The other was treated conservatively. An abdominal computerized tomography (CT) scan with intravenous contrast was helpful in diagnosing the superior MVT in both patients, which were not suspected. Intravenous contrast should be used when performing CT of an appendicular mass. Special interest should be directed at studying the superior mesenteric vein. Early diagnosis of our patients helped to start early medical treatment with anticoagulation.