Iqbal Ali

Effect of cholelithiasis and cholecystectomy on serum lipids and blood glucose parameters

Background: Association between gallstone disease (GSD) and dyslipidemia has been shown in many studies. The aim of this study was to compare the serum lipid and serum glucose levels in patients with and without gallstone and also to determine changes in same parameters in gallstone patients before and after cholecystectomy. Materials and Methods: A total of 71 patients with gallstone (Group A) and 96 without gallstone (Group B) were studied prospectively. Patients in both groups were investigated for GSD. Total cholesterol (TC), triglycerides (TG), high density lipoprotein cholesterol (HDL-c), low density lipoprotein cholesterol (LDL-c), atherogenic index (AI) and fasting glucose (FG) levels were estimated in both groups pre-operatively. Further, same parameters were studied in Group A post-operatively at 1 week and 1 month intervals. Results: The serum levels of TC, TGs, LDL-c, AI and FG were found to be higher and levels of serum HDL-c were lower in gallstone patients than that of the control group, though not statistically significant. In patients with gallstone, significant decrease in TC, LDL-c, TG, AI and increase in HDL-c levels were observed post-cholecystectomy at both intervals. Post-operatively, rise in serum glucose levels at 1 week interval and decrease at 1 month interval were noticed in patients with GSD. Conclusion: GSD is associated with abnormal lipid profile and serum glucose. Cholecystectomy leads to a significant decrease in these parameters except HDL-c in patients with GSD. The presence of gall stones should be perceived in the context of metabolic disorder, which may be investigated and treated. Asymptomatic gallstone patients may also be treated surgically resulting in improvement of above mentioned biochemical parameters.

Fournier's gangrene: A study of 18 cases

Background: Fourniers gangrene (FG) refers to necrotizing fasciitis affecting the perineal, rectal or genital areas. This can have a fulminant presentation, and its clinical course is unpredictable. It can be fatal unless there is prompt recognition and aggressive surgical treatment. We report our experience and results in the management of FG. Materials and Methods: We conducted a prospective analysis of cases of FG presenting to our institute from April 2007 to September 2009. All patients with signs and symptoms of FG were admitted and evaluated. A policy of aggressive surgical debridement under the cover of broad spectrum antibiotics was adopted, often in multiple sittings. Supportive therapy was also provided. Skin grafting and thigh pouch implantation were undertaken where indicated. Results: There were a total of 18 patients. Seven patients were in the age group of 50-59 years. There was delay of 11-15 days in reporting after onset of symptoms in 44.4% of cases. The main pre-disposing risk factors were age above 50 years (61.1%) and diabetes mellitus (33.3%). The route of infection was mostly cutaneous (27.7%). All infections were polymicrobial aerobic infections, and the commonest organisms were Escherichia coli and Klebsiella species. Aggressive surgical debridements were done, often in multiple sittings. The average number of procedures per patient was 3.27 with a range of 2-4. Conclusion: Early and aggressive surgical management are essential to ensure a successful outcome in FG.

The Modified Iliopubic Tract Repair—A Pain-Free Alternative

Background u2003The open preperitoneal repair offers the benefits of placing the mesh in the preferred position while avoiding the disadvantages of laparoscopic repair. Methods u2003A total of 60 patients with bilateral inguinal hernias were randomized to undergo either the standard Lichtenstein meshplasty or the modified iliopubic tract repair in a teaching hospital. Outcomes measured were immediate postoperative pain, return to activity, and delayed neurological complications. Results u2003Patients who underwent the iliopubic tract repair walked out of bed faster than the Lichtenstein group (6.3 hours vs 7.4 hours, p u2009<u20090.0001) and experienced significant lower pain as charted by visual analogue scale scores (3.28 vs 2.71 on day 1, 2.16 vs 1.71 on day 2, 1.92 vs 1.08 on day 3; p u2009<u20090.05). Delayed complications like chronic inguinal pain and numbness were not seen in the iliopubic tract group. However, this difference was not statistically significant ( p u2009>u20090.05). Conclusion u2003The iliopubic tract repair offers an excellent alternative to the Lichtenstein meshplasty, and is associated with lower postoperative pain, earlier return to work, and lower delayed neurological complications.

A Rare Entity of Gastrointestinal Stromal Tumour Arising from a Meckel's Diverticulum: a Case Report.

Meckel’s diverticulum (MD) is the vestigial remnant of omphalomesenteric duct which is also called as vitelline duct, present around the seventh or eighth week of gestation [1]. It is the most commonly encountered congenital anomaly of the small intestine, which affects 2% of the population [2]. Tumours arising from MD are extremely rare and accounts for only 0.5 to 3.2%, according to the available literature [1, 3, 4]. Most common malignant tumour occurring in MD is carcinoid tumour [5]. Gastrointestinal stromal tumour (GIST) from MD is observed only in 12% of overall tumours of MD [6]. We present a curious case of GIST arising from the Meckel’s diverticulum in a middle-aged male who presented with hypogastric lump and provisionally diagnosed as small bowel tumour leading to volvulus on computer tomography (CT). Intra-operative findings confirmed the diagnosis of mass from MD with small bowel volvulus. Patient was successfully treated with derotation of volvulus and excision of tumour with resection anastomosis of small bowel.

Squamous Cell Carcinoma of Colon—an Etiopathological Surprise

Colorectal cancer is the second and third most common cancer in females and males worldwide, with an estimated incidence of 1.4 million new cases per year in the USA. The incidence in India is 4.3 and 3.4 per 100,000 in males and females respectively [1]. Adenocarcinomas are the most commonly encountered type, accounting for 90% of all colorectal malignancies [2]. Squamous cell carcinomas (SCC) of the colon and rectum, however, are extremely rare, with fewer than 100 reported cases in available literature since 1919 and an estimated incidence of 0.025 to 0.1% of all colorectal malignancies [3–7]. The exact etiopathogenesis is still unclear, with a variety of proposed mechanisms. We report a case of a 60-year-old lady who presented with an acute intestinal obstruction due to a malignant lesion in the hepatic flexure of the colon, which on histopathological examination, turned out to be SCC. The scarcity of the available literature made us think whether SCC of the colon is a reality or a myth, and if such an entity exists, is it a primary malignancy or a secondary lesion. Hence, we decided to report this very interesting case.

A study of epidemiological factors and clinical profile of primary varicose veins

Introduction: Varicose veins cause a great deal of morbidity in our population today. They are part of the penalty we pay for the adoption of the erect posture. They affect 10–20% of population in the Western world but in India, it is 5%. Varicose veins do not threaten life and are seldom disabling, but they cause a considerable demand on medical care. They are the cause of morbidity and loss of precious work hours and a significant financial burden on the health-care system. Aims and Objective: To study the epidemiological factors with respect to age, sex, and occupation and clinical profile as per Clinical, Etiologic, Anatomical, Pathophysiological classification of varicose veins. Materials and Methods: A total of sixty cases of were examined at a teaching Medical College, Hospital and Research Centre during the period from July 2013 to September 2015. Examination of patients was carried out according to the pro forma. All patients underwent detailed clinical examination followed by color Doppler ultrasound. Results: In our study, 70% patients were males and 30% patients were females. Maximum patients were in age group of 45–54 years. Twenty were in CEAP C2, 15 cases in CEAP C3 and 15 cases in CEAP C4 and 10 cases in C5. Sixty percent patients had involvement of great saphenous vein (GSV), 17% patients had short saphenous vein (SSV) while 23% patients had involvement of both GSV and SSV. Conclusion: Not only prolonged standing but also sitting posture can cause varicose veins. Obesity and increasing age are other risk factors. Classifying the varicose veins has an impact on the course of the disease and preventing its complications. Color Doppler is superior to clinical examination in the evaluation of superficial and perforator veins incompetence.

A rare case of primary amenorrhea

Crytomenorrhea arises usually due to the imperforate hymen, sometimes due to vaginal septum, rarely due to cervical agenesis. Here, we present a case of primary amenorrhea resulting from cervical agenesis in a 38-year-old woman. She presented with primary amenorrhea and cyclic lower abdominal pain. She had undergone some surgery 5 years back, details of which were not available. On examination secondary sexual characters were normal, per abdomen there was an 18 weeks size firm abdominopelvic mass. Local vaginal examination showed a blind vaginal pouch. A clinical diagnosis of hematometra due to transverse vaginal septum was made. However, magnetic resonance imaging pelvis suggested hematometra with cervical stenosis. The patient was taken up for examination under anaesthesia (EUA) and exploratory laparotomy. On opening the abdomen uterus found to be enlarged with dense adhesions all around and signs of endometriosis. Extensive adhesiolysis revealed bilateral chocolate cysts of ovaries with hematosalpinges and peritubal adhesions. Hysterotomy and drainage of tarry contents were followed by an exploration of the uterine cavity. The lower pole ended blindly with no evidence of any cervix. Peroperative diagnosis of cervical agenesis leading to hematometra and endometriosis was made. A subtotal hysterectomy with bilateral salpingo-oophorectomy was done. Histopathological examination confirmed ovarian endometriosis and adenomyosis of uterus. Though reconstructive surgery for cervical dysgenesis has been successful in some cases, hysterectomy is generally recommended for cervical agenesis.

Role of scoring systems in acute pancreatitis

Background: Identification of patients at risk for severe disease early in the course of acute pancreatitis is an important step to formulating the management strategies for improving outcomes. Scoring systems designed for such assessment need critical evaluation regarding which and when to apply. Aims: To assess the efficacy of specific scoring systems like Ransons score, Bedside Index for Severity in Acute Pancreatitis (BISAP) scoring, Acute Physiology Score and the Chronic Health Evaluation II (APACHE II), and Modified Computed Tomography Severity Index (MCTSI) to predict severity, organ failure, and complications leading to mortality in acute pancreatitis. Materials and Methods: Ransons, APACHE II and BISAP scores were calculated within 24 h of admission. Ransons score was evaluated also after 48 h of admission. CT scan was performed after a period of 48 h only if the clinical course was unpredictable, morphological changes were detected on ultrasound abdomen or on clinical suspicion. MCTSI was evaluated in such cases. Results: There were 48 patients with acute pancreatitis (89.6% male) of which 11 patients underwent contrast-enhanced CT scan. Six patients developed organ failure and were classified as severe acute pancreatitis. Three patients had died. Six patients had a BISAP score >3, 5 patients with Ransons score >3, 3 patients with APACHE II >8 and MCTSI >2 was seen in 9 patients. Area under curve for BISAP, Ransons, APACHE II, and MCTSI in predicting severity are 0.79 (confidence interval [CI]: 0.605-0.967), 0.79 (CI: 0.524-1), 0.94 (CI: 0-1), and 0.61 (CI: 0.286-0.936), respectively. Conclusion: We recommend that although APACHE II score is a better predictor of organ failure, BISAPS should be used for the identification of high-risk patients because of its simplicity. Ransons score still holds its place in identifying patients at risk of developing severe acute pancreatitis and organ failure. MCTSI though did not perform well, but still helps to identify local and systemic complications without pancreatic necrosis. It also defines scope and extent of the surgical intervention.

Duodenal tuberculosis mimicking superior mesenteric artery syndrome

Tuberculosis of stomach and duodenum is quite uncommon. Its preoperative diagnosis still remains a challenging problem for surgeons. Herein, we report the case of isolated abdominal tuberculosis in a 28 years old male presenting with features of gastric outlet obstruction due to stricture in duodenum. Oesophagogastroscopy revealed doubtful extrinsic compression of first part of duodenum with mild gastritis. CECT abdomen showed pronounced dilatation of stomach, 1 st and 2 nd part of duodenum with narrowing and compression of 3rd part of duodenum between superior mesentric artery and aorta; suggesting superior mesenteric artery syndrome (SMA). He was taken up for exploration which revealed peritoneal, small and large bowel mesentery and mesocolon seedlings. Mesenteric lymphadenopathy was seen and duodenum showed narrowing between 1 st and 2 nd part of duodenum with proximal dilated and distal narrow duodenum without any compression by SMA. Duodeno-duodenostomy was done. Histopathological examination of biopsied mesenteric lymph node was consistent with the features of tuberculosis. Patient was started on anti-tubercular therapy. His symptoms were relieved and he gained weight rapidly.

Benign Liver Lesions: AClinical Profile

The diagnosis of benign liver lesions have been increased due to current imaging modalities and liver function test. Early detection of benign liver lesions by various imaging modalities of liver function test (LFT) can be treated by non-invasive methods. Benign liver lesions include a broad spectrum of pathologies ranging from regenerative nodules to true neoplastic processes and various cystic lesions. In this study, 50 cases were studied, age ranging from 19 years to 86 years. Age wise distribution of cases in study group showed that majority of cases were between 21-30 years age group. Amoebic liver abscess is the commonest lesion, which is common in males of 21-40 years. Cavernous hemangioma is the commonest solid lesion with female to male ratio of 2:1. Ultrasonography (USG) is the primary initial investigation in diagnosing benign lesions.