Barun Kumar Sharma

Scapular bone destruction: do not forget to think of tuberculosis in endemic areas.

Tuberculosis is an endemic disease of worldwide concern. The most common involvement is in the form of pulmonary tuberculosis. Musculoskeletal system is involved in 20–30% of cases of extrapulmonary tuberculosis. Among these cases of musculoskeletal tuberculosis, vertebral column is most commonly involved followed by long bones. However, tuberculosis of flat bones like scapula is very rare. We present a case of a 56-year-old woman with painless swelling in the right lower back of chest. Ultrasonography suggested abscess formation. A chest X-ray and CT scan suggested coexisting pulmonary tuberculosis. CT revealed abscess with osteomyelitis of inferior angle of scapula. The abscess was aspirated and histopathological examination confirmed tubercular pathology. A 6-month course of antitubercular treatment resulted in complete resolution of symptoms.

Obesity Not Necessary, Risk of Symptomatic Cholelithiasis Increases as a Function of BMI

INTRODUCTION Obesity is a well-established risk factor for cholelithiasis. But most of the studies have actually tried to establish the risk of cholelithiasis in overweight and obese people. Very few studies have addressed the issue of cholelithiasis in patients with otherwise normal Body Mass Index (BMI). In this study we have tried to establish if there is any relationship between increasing BMI and cholelithiasis. AIM To establish a relationship between increasing BMI and risk of cholelithiasis. MATERIALS AND METHODS Retrospective analysis was carried out after doing a prospective pilot study. Ten years data of patients admitted to surgery ward with complaints of pain abdomen was reviewed. Patients with cholelithiasis were segregated as cases and patients with some other diagnosis were selected as controls. Patients with incidental diagnosis of cholelithiasis were excluded. Appropriate analytical tools were used to draw the results using SPSS© 20. RESULTS Over 11,000 patients data was reviewed and 7,182 patients were selected for inclusion into the study. Major exclusion was due to incomplete availability of data. Cholelithiasis group had 2,872 patients and rest of the patients served as controls against them. Female patients outnumbered their male counterparts in cholelithiasis group. Mean age of the gallstone patients was 37.09 years, almost 2 years younger than their controls. Mean BMI of all patients was 23.55 kg/m2 and in cholelithiasis and control group was 24.93 and 22.62, respectively (df=1, F>1635.395, p<0.001). Gender specific comparison also yielded a significant difference df=3, F=547.238, p<0.001). The difference in the way the patients were distributed among the ethnic groups (Nepalis, Bhutias, Lepchas and others) was also significant (df=3, F=34.234, p<0.001). Most important outcome was that the majority of the patients in the cholelithiasis group were within the normal BMI range. CONCLUSION We concluded that its not only the overweight or obese patients who develop symptomatic cholelithiasis but also the individuals with normal BMI. The risk of symptomatic cholelithiasis increases with every increase in BMI. Risk of symptomatic cholelithiasis also increases in women and as the age advances.

Comparative Evaluation of Ultrasonography and Cross-sectional Imaging in Determining Gall Bladder Perforation in Accordance to Niemeier’s Classification

INTRODUCTION Gall Bladder (GB) perforation, a rare but dreaded complication of acute cholecystitis and is associated with high mortality rate. Early detection of acute cases of GB perforation reduces the risk of biliary peritonitis and hence the associated mortality and morbidity. AIM The purpose of the study was to make a comparative evaluation of the role of Cross-sectional imaging in GB perforation with base line investigation like sonography. Finally both modalities were compared in determining the type of perforation according to Niemeiers classification. MATERIALS AND METHODS We retrospectively evaluated the Ultrasonography (USG), Computed Tomography (CT) and Magnetic Resonance Imagings (MRI) findings in patients of GB perforation with surgical correlation. RESULTS We evaluated 17 patients of GB perforations over a time period of one year. USG was done in all patients. As cross-sectional modality only CT scan was done in 14 patients and MRI scan was done in four patients. Both CT and MRI scans were done in one patient. CONCLUSION Cross-sectional imaging must not be delayed in suspected cases of GB perforations because it helps in establishing a quicker diagnosis, detecting complications and also helps in decision making related to management thereby reducing the morbidity and mortality associated with this condition.

Fetus Papyraceous in Uniovular Twin; Death of One Twin in Early Third Trimester and Successful Outcome of Other Twin at Term: A Rare CaseReport

Fetus papyraceous is a rare obstetric complication in multiple gestations, the incidence of which in case of twin is 1 in 12,500. It may be associated with high maternal and fetal complications including disseminated intravascular coagulation induced death and organ damage. Fetus papyraceous can occur both in uniovular and binovular twin pregnancies. However intrauterine death is three times more common in case of uniovular twin because of frequency of vascular connections (85-98%) in monochorionic placenta. Here, we report a case of uniovular twin pregnancy with one twin fetus papyraceous in early third trimester and pregnancy continued till term with a successful outcome of surviving co-twin.

A case of putty kidney without pulmonary tuberculosis.

A 30-year-old woman presented with a 1-year history of a dull ache in her left flank along with recent onset of hypertension. There was no history suggestive of tuberculosis and examination was unremarkable. X-ray showed dense opacity in left renal area. Contrast-enhanced CT revealed a non-enhancing and non-excretory left kidney suggesting autonephrectomy. When a 6 week course of antituberculous therapy (ATT) failed to alleviate her symptoms, surgical nephroureterectomy was performed which resulted in complete resolution of symptoms and well-controlled blood pressure without any medication.

Ruptured Primary Ovarian Pregnancy Presented in Advanced Gestation without Amenorrhoea: A Rare Case Report

A 28 year old gravid 2 para 1 living attended emergency department of our hospital complaining of pain in the abdomen for one day and light vaginal bleeding for one hour duration. She did not give any history of amenorrhea even after repeated enquiry and her previous menstrual cycles were reported to be normal in amount, duration and flow. She gave no history of sexually transmitted disease, pelvic inflammatory disease or any previous gynecological surgery. Her first pregnancy was a spontaneous conception and she had a full term normal vaginal delivery which was a hospital delivery. There were no post partum complications and no history of contraceptive use.

A weeping umbilical hernia: bilateral ovarian mucinous cystadenoma with disseminated peritoneal adenomucinosis

A young woman was referred to us for the management of an umbilical hernia with macerated overlying skin through which massive ascites was leaking. On examination we found a jelly-like substance seeping out of the opening. A contrast-enhanced CT scan of the abdomen revealed bilateral ovarian cystadenocarcinoma with pseudomyxoma peritonei. The patient underwent cytoreductive surgery along with hysterectomy and bilateral oophorectomy followed by hyperthermic intraperitoneal chemotherapy with mitomycin C. Histopathological examination showed bilateral borderline cystadenoma with peritoneal adenomucinosis. Follow-up at 1 year showed no signs of recurrence.

Rare event of biliary papillomatosis arising in a choledochal cyst

A 31-year-old man presented with features of recurrent cholangitis for 7 months. Examination revealed icterus and a palpable 10×8 cm lump in the right hypochondrium extending into the epigastrium. Total and direct bilirubin was raised (8.4, 6.7 mg/dL). Alkaline phosphatase (468 U/L) was raised but other liver enzymes were normal. Ultrasound of the abdomen showed dilated intrahepatic biliary radicals (IHBRs) and common hepatic duct (CHD) with a significant intrahepatic portion. Contrast-enhanced CT scan of the abdomen showed similar findings. MR cholangiopancreatography demonstrated diffusely dilated IHBRs and choledochal cyst involving the CHD. The common bile duct was mildly dilated without any filling defect. Tumour markers (carcinoembryonic antigen and cancer antigen 19-9) were normal. The patient underwent complete excision of the extrahepatic biliary system including choledochal cyst and Roux-en-Y hepaticojejunostomy. Opening up the bile duct showed very thick gelatinous material and multiple pedunculated papillary type structures arising from the wall of the choledochal cyst.