Afzal Anees

Lifestyle and gallstone disease: scope for primary prevention.

Objective: To study the antecedent risk factors in the causation of gallstone disease in a hospital-based case control study. Materials and Methods: Cases (n = 150) from all age groups and both sexes with sonographically proven gallstones were recruited over a duration of 3 months from the surgical wards of a tertiary care teaching hospital. Modes of presentation were also noted among cases. Age- and sex-matched controls (n = 150) were chosen from among ward inmates admitted for other reasons. Univariate and multivariate logistic regression analyses were performed for selected sociodemographic, dietary, and lifestyle-related variables. Results: Females had a higher prevalence of gallstone disease than males (P < 0.01). Among males, the geriatric age group (<60 years) was relatively more susceptible (28%). Prepubertal age group was least afflicted (3.3%). Univariate analysis revealed multiparity, high fat, refined sugar, and low fiber intakes to be significantly associated with gallstones. Sedentary habits, recent stress, and hypertension were also among the significant lifestyle-related factors. High body mass index and waist hip ratios, again representing unhealthy lifestyles, were the significant anthropometric covariates. However, only three of these, viz., physical inactivity, high saturated fats, and high waist hip ratio emerged as significant predictors on stepwise logistic regression analysis (P < 0.05). Conclusion: Gallstone disease is frequent among females and elderly males. Significant predictor variables are abdominal adiposity, inadequate physical activity, and high intake of saturated fats; thus representing high risk lifestyles and yet amenable to primary prevention.

Kikuchi-Fujimoto Disease: Diagnostic Dilemma and the Role of Immunohistochemistry

Kikuchi-Fujimoto (KD) disease is the rare differential diagnoses of chronic cervical lymphadenopathy of unknown etiology. The findings of histopathology may be overlapping, in such condition immunohistochemistry has a definite role to play. Since Tubercular lymphadenopathy is the commonest cause for chronic cervical lymphadenopathy in developing and tropical country like India. Occasionally it is misdiagnosed, ignoring the other rare condition like KD if immunohistochemistry is not taken into consideration to differentiate. As a result the morbidity increases and cost of antitubercular treatment (ATT) in wrong diagnosed case is enormous. We report a similar case of misdiagnoses, non responsive to ATT, finally diagnosed as a case of Kikuchi-Fujimoto disease, did well after recommended treatment. Keywords Necrotizing lymphadenitis; Chronic cervical lymphadenitis; Immunohistochemistry

Hydatid Disease of the Intestine Manifesting as Acute Abdomen: A Case Report

To the Editor: We report here an unusual case of hydatid disease presenting as acute abdomen. Although the liver and lung are the most common locations for larval cysts of Echinococcus granulosus in humans, these cysts may develop in the abdominal or pelvic cavity and, more rarely, else where in the body ( 1 ). Echinococcal infection is characterized by its long clinical latency, allowing only late diagnosis and permit ting the disease to become extensive ( 2 ). Aft er a variable incubation period, infection may become symptomatic if cysts grow and place pressure on the adjacent tissue and induce other pathological changes ( 3 ). A 25-year-old man presented with abdominal pain and vomiting. Pain was present all over the abdomen but was most severe on the right lower abdomen. Th ere was no history of fever. On examination there was no tenderness, but a solid mass was palpable in the right lower quadrant. Hematological investigations revealed a hemoglobin level of 11 g / dl, a total leukocyte count of 8900 cells / μ l, and a diff erential count of 68 % polymorphs, 30 % lymphocytes, and 2 % eosinophils. Th e results of a liver function test and levels of urea and creatinine were all within the normal range. Montoux test was negative, and chest radiography showed no abnormality. A barium-meal followthrough study revealed narrowing of the distalmost part of the terminal ileum, with fi brosis, contracture, and distortion of the cecum, which was pulled up ( Figure 1a ). Exploratory laparotomy showed a dense fi brotic mass involving the distalmost part of the ileum and the entire cecum. Dense adhesions were present between the large bowel and the parietal peritoneum. Gross examination of the ileocecal region detected a fi rm mass measuring 5.5 cm in diameter, which on cut section appeared solid grayish-white with areas of lobulation and fi brosis of the laminated membrane along with foci of hemorrhage ( Figure 1b ). Histopathological examination confi rmed inactive hydatid disease ( Figure 2 ). Hydatid disease in humans is a zoonotic infection caused by larval cysts of E. granulosus , for which humans are an intermediate host ( 4 ). Only three species of Echinococcus — E. granulosus , E. multilocuralis , and E. vogeli — are of medical importance. E. granulosus is the most common causative agent of hydatid disease ( 5 ). Although the liver and lung are the most common locations for the larval cyst of Echinococcus in humans, these cysts may develop at other sites and cause signs and symptoms that can easily be confused with those of other illnesses ( 6 ). Diagnosis of a hydatid cyst does not pose much diffi culty when it presents as a cystic mass, but when it presents as a solid mass, it is diffi cult to diff erentiate it from granuloma or tumors — as in our case, in which the patient presented with a solid ileocecal mass mimicking a neoplasm. Anaphylactic shock, cyst infection of the biliary tree, and rupture into peritoneum are the most severe complications ( 7 ). Kusasalem et al. ( 7 ) reported a case of primary mesenteric hydatid cyst presenting as acute abdomen, and Turdibaev et al. ( 8 ) reported rupture of an echinococcal cyst of the small intestinal mesentry simulating acute appendicitis ( 7,8 ). Our case did not have such complications. Many hydatid cysts remain asymptomatic even in their advanced stages. Symptoms can be produced by mass eff ect or cyst complications. Symptoms due to pressure usually take a long time to manifest, except when they occur in the brain or the eyes ( 9 ).

The role of laboratory investigations in evaluating abdominal tuberculosis.

Background and Objectives: Tuberculosis (TB) continues to be a major health problem in developing countries like India. Abdominal TB is defined as an infection of the peritoneum, or hollow or solid abdominal organs with Mycobacterium tuberculosis (Mtb). The gastrointestinal tract is one of the most frequent sites of extrapulmonary involvement in TB. The present study was undertaken to evaluate the role of laboratory investigations in the diagnosis of abdominal TB. Materials and Methods: The study was conducted on 300 patients admitted to various departments of our hospital from November 2005 to October 2007. Detailed histories and thorough clinical examinations together with relevant hematological, biochemical, cytological, radiological, and histopathological investigations were carried out in suspected cases of Koch′s abdomen. Results: Erythrocyte sedimentation rates with positive results were seen in 79.3% patients. Serological test enzyme-linked immunosorbent assay was performed on only 30 patients and was found to be positive for IgG, and IgM in 25 cases with a sensitivity of 83%. Thirteen out of 15 cases were positive for adenosine deaminase done on ascitic fluid. The results of the two patients who underwent Mtb polymerase chain reaction (PCR) were consistent with TB. Out of 21 image-guided fine-needle aspiration cytology (FNAC) cases, 10 (48%) of the positive cases showed caseating necrosis while 7 (33%) had noncaseous necrosis. Stain for acid-fast bacilli (AFB) was performed on all cases and was positive in 42 cases (38.8%). Lymph node biopsy was done in 95% of the cases. Conclusions: Serological investigations have a limited value, while PCR is a highly specific test. Since cost restricts its use, only two patients in our study could afford it. BACTEC is more sensitive and faster than culture techniques for the diagnosis of mycobacterial infections. FNAC is a reliable, cost effective alternative, and 81% diagnostic yield in the present study suggests that ultrasound guidance is a useful tool. Histopathological evaluation with positive AFB staining remains the gold standard for diagnosing abdominal TB. However, although the demonstration of AFB in aspirates and tissue sections is a definitive diagnostic method for TB, the positivity for AFB is variable.

Septic disruption of lactiferous ducts with heterogeneous carcinoma of the breast in a lactating woman.

This report documents the diagnostic histopathological features of heterogeneous breast carcinoma following sepsis and disruption of the lactiferous ducts in a lactating woman and discusses the pathogenesis. Sections from the nipple revealed disrupted collecting lactiferous ducts presenting with intraduct precarcinoma and carcinoma of the epidermoid type, and attached reparative sprouts lined by lactiferous cells. Breast lobules showed generalised benign adenotic change with various foci of carcinoma microscopically identifiable as intraduct primitive lactiferal ectodermal carcinoma, lactating carcinoma, primitive neuroendocrine carcinoma and myoepithelioid granulomatous carcinoma. The findings led to the conclusion that the lactiferous ducts are susceptible to sepsis and disruption, which may predispose a patient to breast carcinoma. The pattern of carcinoma suggested that lactiferous epithelial cells behaved colonially, with different metaplastic changes, precarcinoma and carcinoma.

Primary cecal pathologies presenting as acute abdomen and critical appraisal of their current management strategies in emergency settings with review of literature

Background: The importance of cecal pathologies lie in the fact that being the first part of the large intestine, any disease involving the cecum affects the overall functioning of the large bowel. Primary cecal pathologies presenting as acute abdomen have not been described in any previous study in terms of presentation, management, and outcome. Objectives: The objective of this study was to identify the reported causes of primary cecal pathologies presenting as acute abdomen and the various causes presenting in our setting, the to discuss morbidity and mortality associated with cecal pathologies, and to critically analyze the various management modalities employed in an emergency setting. Materials and Methods: This is a retrospective analysis of a prospectively collected data of all adult patients admitted to our unit in the last 10 years for acute abdomen, in whom cecal pathology was identified as the primary offending agent. Results: Our analysis of 43 patients revealed cecal perforation secondary to amebic colitis along with the simultaneous presence of liver abscess to be the most common primary cecal entity met in practice as acute abdomen. Other pathologies that were encountered included volvulus, diverticulitis, and idiopathic typhlitis. Primary acute cecal pathologies are associated with high mortality rates (≈42%). Delay in diagnosis seems to be the most important factor contributing to high mortality as these conditions are commonly misdiagnosed as appendicular pathology. Most of our patients were managed by conservative colonic resection with proximal diversion. This seems to be a more plausible option in current practice in an emergency setting (mortality rate ≈ 36%) as hemicolectomy is associated with proportionately higher mortality rates (67%). Conclusion: A high index of suspicion, timely and adequate pre-operative workup, optimal resuscitation, and surgical conservatism with proximal diversion might help in early accurate identification of these conditions and possibly improved outcome.

Efficacy of Narrow Band Imaging in Detecting Lower Gi Lesions and Its Histologic Correlation

Background: To evaluate the efficacy of Narrow band imaging (NBI) in detecting lower GI lesions and differentiation on the basis of color, vascular pattern and surface pattern findings on NBI with histopathologic correlation. Material and Methods: 94 patients of both gender, with lower GI symptoms were subjected for lower GI endoscopy by conventional white light endoscopy and CLV-190 HD colonoscope having Narrow-band imaging (NBI) as standard feature after obtaining an informed consent. Patients who did not give consent, patients with severe inflammatory bowel disease and who lost during follow up were excluded from the study. All NBI findings of suspected lesions were classified according to NICE (NBI International Colorectal Endoscopic) classification, into hyperplastic lesion, adenomatous and invasive carcinoma. Biopsies were taken and stained with Haematoxylin and Eosin as well as Periodic Acid Schiff stain. Statistical analysis was done to compare NBI diagnosis with the histopathological diagnosis. Results: Majority of the patients were in the third decade of life, with a mean age of 36.22 years. Diarrhea was the commonest clinical presentation, in 60 (63.8%) patients. NBI was suggestive of ulcerative colitis/Inflammatory bowel disease (IBD) in 59 (62.8%) patients, neoplastic polypoidal lesion in 24 patients (25.5%) and polypoidal non-neoplastic lesion in 11 (11.7%) patients. Out of 59 (62.8%) cases of Ulcerative colitis (UC), 35 (37.2%) were polypoidal, among which 24 (68.6%) were suggestive of neoplastic polypoidal lesion (NICE II-III) and 11(31.4%) were non-neoplastic polypoidal lesion (NICE I). Out of 59 cases of UC, clear mucosal vascular pattern (MVP) was found in 11 (18.6%) cases and obscure MVP in 48 (81.4%) cases. Conclusions: NBI provides a unique image with contrast enhancement and can emphasize the capillary pattern and surface architecture and plays a major role in the differentiation of neoplastic and non-neoplastic colorectal lesion, with high sensitivity and specificity.

Tubercular esophagocutaneous fistula: A rare case

Tubercular esophagocutaneous fistula is a very rare complication arising either due to erosion by caseating cervical lymph nodes or due to tuberculosis (TB) of the esophagus. Both of these conditions are themselves rather sporadic. A young male presented with a passage of “orally taken liquids” from an opening in the neck. He had no primary foci of TB detected whatsoever, which was unusual. He was started on antitubercular treatment (ATT) for 8 weeks, but due to nonclosure of tract, the fistula had to be excised. Histopathology confirmed the tubercular nature of tract. ATT was continued postoperatively. There has been no recurrence even after 1½ years of follow-up.

Amyand's hernia masquerading as a strangulated inguinal hernia: A case report and literature review

We report a rare case of a 62-year-old male who presented to surgical emergency department with the complaints of sudden onset pain and swelled in the right inguinal region with nausea, vomiting and abdominal distension. There was a history of a reducible swelling in the right inguino-scrotal region for the last 1 year. Based on history, clinical examination and investigations a provisional diagnosis of right-sided strangulated inguinal hernia was made and patient was planned for an emergency surgery. On the exploration, the hernial sac revealed a gangrenous vermiform appendix and the diagnosis of Amyands hernia was made. Appendectomy was performed through the same incision, and hernial repair was done using a polypropylene mesh.