How Predictive are the Signs and Symptoms of Small Bowel Obstruction.

OBJECTIVE: The present study aims to determine the diagnostic significance of signs and symptoms of Small Bowel Obstruction (SBO) and to ascertain if there was any delay in presentation of the patients to the hospital. METHODS: This retrospective case study spanning 3 years was conducted at Riyadh Medical Complex, Saudi Arabia. All adult patients admitted from the ER with a diagnosis of SBO were included in the study. The medical records of the patients with International Classification of Diseases (ICD) 9 codes 552.8, 560, 560.8, 560.81 and 560.9 were searched and retrieved. RESULTS: A total of 195 patients were included in the study out of which 174 patients had a definitive diagnosis of SBO. The study group was composed of 76.4% males and 71.8% were aged between 20 years to 60 years. The mean duration of symptoms was 4.8 days, ranging from 6 hours to 17 days. The cardinal signs and symptoms of obstruction had low sensitivity (Range: 56-75), and specificity (Range: 28-61), but relatively high positive predictive value (PPV) (Range: 86-93). The morbidity was 13.8% while mortality was 3.4%. CONCLUSION: The cardinal features of SBO are neither specific nor sensitive, and though they may have an acceptable PPV, the predicted rate of false positive diagnosis is unacceptable. Therefore, the clinician may not rely on the clinical picture alone for the diagnosis of SBO. The presentation of the studied patients was delayed compared to the literature and it may be an important factor in increasing morbidity and mortality, but this aspect needs to be studied further.

Pseudomyxoma peritonei. Presenting as a localized perforation of the cecum.

Pseudomyxoma peritonei (PMP), also known as jelly belly, is a rare condition with mucinous material spread throughout the abdomen. It can arise from the appendix, colon, or even a teratoma. The documented incidence is one per million per year. We present a case report of an 80-year-old female patient presenting with PMP secondary to an appendicular tumor leading to localized infiltration, and perforation of the cecal wall. A review of the literature was carried out, with emphasis on various treatment options available for this rare condition.

Surgical management of colonic volvulus during same hospital admission.

OBJECTIVE: To study the local patient profile, diagnostic methods, and treatment outcome in patients with large bowel volvulus to recommend a management plan. METHODS: A retrospective study of patients record with a final diagnosis of large bowel volvulus treated at King Saud Medical Complex, Riyadh, Saudi Arabia between January 2000 and December 2007 were performed for patient demography, clinical presentations, co-morbidity, diagnostic methods, anatomical types, management, and outcome. RESULTS: Forty-two patients with large bowel volvulus were reviewed. They represented 8.5% of all intestinal obstructions treated. Most had sigmoid volvulus (83%), were less than 60 years of age, and were male. Recognized risk factors were present in 12 (29%) patients. Diagnosis was suspected on plain abdominal x-ray in 28 patients (69%), although the characteristic signs of omega and coffee bean were seen in only 16 patients. Eight patients required emergency surgery. Endoscopic decompression was successful in 34 patients, followed by a definitive surgery in 24 patients. Seven patients refused surgery; 3 of them were readmitted with recurrence and were operated. Three patients were unfit for surgery. There were 3 deaths. CONCLUSION: Large bowel volvulus is uncommon in this area. Abdominal distension with pain, constipation, and characteristic gas pattern in plain x-ray can help diagnose most cases. Decompression can be achieved in most patients with sigmoid volvulus, followed by surgery during the same hospital admission. Transverse colon and cecal volvulus usually need emergency surgery.

Cystic echinococcosis in Central Saudi Arabia: a 5-year experience.

BACKGROUND/AIMS: In this series of patients we aim to describe aspects of presentation, diagnosis and management of patients suffering from Echinococcosis in an endemic region. METHODS: This is an observational study done at Riyadh Medical Complex, Saudi Arabia from 1999 to 2004. All adult patients admitted with the primary or incidental diagnosis of echinococcosis were included. These patients were followed up for 6 months. Data relating to patients' demographic characteristics, mode and duration of presentation, investigations, complications and treatment offered was collected. This data was then analyzed using SPSS 11.0. RESULT: 117 patients with a mean age of 40.9+/-20.7 years were admitted, male to female ratio being 1.7:1. 114 (97.4%) originated from Middle East which is an endemic area. Pain right upper quadrant (RUQ), followed by cough were the commonest symptoms. Nine patients presented with jaundice +/- choleangitis: 3 patients had intrabiliary rupture of the hydatid cyst, while 6 had extrinsic compression. Six patients had infected cyst. Fourteen patients had intrabronchial rupture diagnosed on bronchoscopy. Twenty five (21.4%) patients presented with recurrent disease. The Haemagglutination Inhibition test gave a sensitivity of 78.6. All cysts were visualized using USG, CXR and CT scan. Endocystectomy was the most frequent procedure. Post op 8 patients had biliary leakage and 3 had bronchopleural fistula a majority of whom settled conservatively while two required ERCP and one patient with bronchopleural fistula required surgery. Fifteen patients had infection related complications. During our follow up period no recurrences were recorded. All patients undergoing surgery also received medical treatment. Twenty five patients (21.4%) were unable to undergo operative treatment due to multiple reasons. They were medically treated. CONCLUSION: Cystic Echinococcosis is a disease of the middle aged. Ultrasonogram combined with a serological assay is the best diagnostic tool available for abdominal echinococcosis allowing diagnosis and staging, while chest X ray is the best screen for the pulmonary disease. The recommended treatment is endocystectomy with antihelmenthic therapy. But the problem of early detection of echinococcosis in endemic areas needs attention by workers as this approach can potentially prevent the devastating complications due to this disease.

Squamous cell carcinoma of colon and rectum.

Primary squamous cell carcinoma SCC of the colon and rectum is a rare malignancy. Less than 100 cases have been reported in literature. We report 2 cases of pure SCC involving the rectum and sigmoid colon. A review of literature has been made starting from the first report in 1919 to the present. We have examined the theories regarding the etiology, available treatment modalities, and prognosis for this variant of colorectal carcinoma. We conclude that this tumor presents later than adenocarcinoma and follows an aggressive course. With a greater awareness among surgeons and pathologists, more cases may become known leading to a better estimation of prevalence and clinicopathological behavior of this tumor.

Value of water-soluble contrast (meglumine amidotrizoate) in the diagnosis and management of small bowel obstruction.

INTRODUCTION: The object of the present study was to determine the effectiveness of a water-soluble contrast follow-through study for differentiating complete from incomplete small bowel obstruction (SBO) and for predicting the need for surgery. METHODS: This prospective study was conducted at Riyadh Medical Complex, Saudi Arabia and spanned 2 years. All adult patients admitted with SBO were included, except those with obstructed hernias, peritonitis, or postabdominal irradiation. The initial resuscitation meglumine amidotrizoate (Gastrografin) follow-though was performed and was considered positive for complete obstruction if the contrast failed to reach the colon as shown on the 24-hour film. Patients were operated on only if they developed signs of strangulation or failed to improve within 48 hours. RESULTS: Our study group consisted of 73 patients, 48 (65.7%) of whom were male. The mean age was 35.70+/-12.65 years. In 60 (82.2%) patients, contrast reached the ascending colon within 24 hours, giving a definitive diagnosis of incomplete obstruction; among these 60 cases, 49 (81.7%) resolved on conservative management. The other 13 (17.8%) patients were diagnosed as having a complete obstruction; 4 (30.8%) of them were treated conservatively, and 9 (69.2%) underwent surgery. Therefore the sensitivity, specificity, positive predictive value, and negative predictive value for meglumine amidotrizoate follow-through as an indicator for operative treatment of SBO were 45.0, 92.5, 81.7, and 69.2, respectively. The P value using Fisher's exact test was 0.0006. CONCLUSIONS: We can confidently diagnose complete and incomplete SBO and differentiate one from the other. This accurate diagnosis indicates a high chance of success with conservative management for incomplete obstruction but does not always correlate with the need for surgical intervention.

A comparison between presenatation time and delay in surgery in simple and advanced appendicitis.

BACKGROUND: Acute appendicitis is the most common cause of acute abdomen. Serial examinations and investigations increase diagnostic accuracy. But this causes delay, which may result in gangrene and perforation. Our aim is to determine the affect of delay by the patient as well as by the physician on the stage of the disease as determined intraoperatively and to determine the percentage of negative appendectomies. METHODS: 102 consecutive patients presenting to the Mayo Hospital emergency, undergoing appendectomy between February and April, 2002 comprise the study group. Data was tabulated and analyzed. The delay by the patient in presenting to emergency was called the "patient's delay" and the in-hospital delay before the actual operation called the "physician's delay" were calculated. The appendicitis was divided into two groups i.e. "simple appendicitis" which included acutely inflamed appendices and grossly mildly or non inflamed but histopathologically inflamed appendicitis and "advanced appendicitis" which included gangrenous and perforated cases. RESULTS: The percentage of negative appendectomy in our center was 5.9%. Patients' delay averaged 2.59 days and 2.43 days in simple and advanced appendicitis. A prolonged average delay period of 6.12 day was seen in misdiagnosed cases. The mean delay was not significantly different. 86.3% of the patients were operated within 12 hours of presentation. The mean physician's delay was 9.24 hours. It was significantly shorter for advanced appendicitis as compared to simple appendicitis. CONCLUSIONS: Patient's delay was not associated with advanced appendicitis. It is recognizable clinically and gets operated two hours earlier on average. There is a significant lag period of observation leading to a physician delay in simple appendicitis, contributing possibly to, increased morbidity. However there is an increased need to use ultrasonography and CT in the emergency setting to diagnose appendicitis in case of doubt.