Nj Jebbin

Deep vein thrombosis: a clinical review.

Background: Deep vein thrombosis (DVT) is the formation of blood clots (thrombi) in the deep veins. It commonly affects the deep leg veins (such as the calf veins, femoral vein, or popliteal vein) or the deep veins of the pelvis. It is a potentially dangerous condition that can lead to preventable morbidity and mortality. Aim: To present an update on the causes and management of DVT. Methods: A review of publications obtained from Medline search, medical libraries, and Google. Results: DVT affects 0.1% of persons per year. It is predominantly a disease of the elderly and has a slight male preponderance. The approach to making a diagnosis currently involves an algorithm combining pretest probability, D-dimer testing, and compression ultrasonography. This will guide further investigations if necessary. Prophylaxis is both mechanical and pharmacological. The goals of treatment are to prevent extension of thrombi, pulmonary embolism, recurrence of thrombi, and the development of complications such as pulmonary hypertension and post-thrombotic syndrome. Conclusion: DVT is a potentially dangerous condition with a myriad of risk factors. Prophylaxis is very important and can be mechanical and pharmacological. The mainstay of treatment is anticoagulant therapy. Low-molecular-weight heparin, unfractionated heparin, and vitamin K antagonists have been the treatment of choice. Currently anticoagulants specifically targeting components of the common pathway have been recommended for prophylaxis. These include fondaparinux, a selective indirect factor Xa inhibitor and the new oral selective direct thrombin inhibitors (dabigatran) and selective factor Xa inhibitors (rivaroxaban and apixaban). Others are currently undergoing trials. Thrombolytics and vena caval filters are very rarely indicated in special circumstances.

Tube Thoracostomy: Complications and Its Management

Background. Tube thoracostomy is widely used throughout the medical, surgical, and critical care specialities. It is generally used to drain pleural collections either as elective or emergency. Complications resulting from tube thoracostomy can occasionally be life threatening. Aim. To present an update on the complications and management of complications of tube thoracostomy. Methods. A review of the publications obtained from Medline search, medical libraries, and Google on tube thoracostomy and its complications was done. Results. Tube thoracostomy is a common surgical procedure which can be performed by either the blunt dissection technique or the trocar technique. Complication rates are increased by the trocar technique. These complications have been broadly classified as either technical or infective. Technical causes include tube malposition, blocked drain, chest drain dislodgement, reexpansion pulmonary edema, subcutaneous emphysema, nerve injuries, cardiac and vascular injuries, oesophageal injuries, residual/postextubation pneumothorax, fistulae, tumor recurrence at insertion site, herniation through the site of thoracostomy, chylothorax, and cardiac dysrhythmias. Infective complications include empyema and surgical site infection. Conclusion. Tube thoracostomy, though commonly performed is not without risk. Blunt dissection technique has lower risk of complications and is hence recommended.

Hepatocellular carcinoma in Port Harcourt, Nigeria: clinicopathologic study of 75 cases.

BACKGROUND Hepatocellular carcinoma (HCC) is a complication of liver cirrhosis caused by hepatitis B viral infection, fungal infection and genetic factors. This disease though having a silent course is associated with variable morbidity and mortality in this environment. METHODS Previously prepared histologic slides were retrieved and re-evaluated to confirm the diagnosis. Clinical data such as the age, sex, clinical presentations, histologic grading and cause of death were extracted from the case notes, histology request forms and autopsy protocol forms. RESULTS Seventy five cases were used for the study during the period under review. The youngest was a 14 year old male while the oldest was a 66 years old male. Male to female ratio was 2:1. Majority (28%) occurred in the age group 40-49 years. Upper abdominal mass was the most common clinical presentation (30.7%) and well differentiated hepatocellular carcinoma was the most common (64.0%) histologic grade. Trabecular inusoidal pattern (49.3%) was the most common histologic type (pattern) while upper gastro-intestinal bleeding (38.7%) was the most common cause of death at autopsy. CONCLUSION Hepatocellular carcinoma is a notable malignancy of the liver associated with variable morbidities and mortality as it has an insidious onset and very aggressive course.

Gossypiboma: a report of 2 cases.

BACKGROUND Retention of surgical sponges in body cavities (gossypiboma) is preventable. It is probably under reported, may be for medicolegal reasons. We report 2 cases we have managed, one at a tertiary medical centre, and the other, at a private clinic in Port Harcourt, in order to re-awaken the awareness of its occurrence and make a plea for caution during surgery. METHODS The case notes of patients treated surgically over the period between 1995 and 2004 were reviewed for cases of retained surgical sponges. RESULTS Two cases were identified over the period 1995 to 2004. One had presented acutely while the second case presented in a sub-acute manner. Both required re-exploration and retained sponges were retrieved. CONCLUSION It may not be possible to eradicate the occurrence of retained sponges in the body but it can definitely be minimized, thus saving many patients from the associated agony.

An audit of basic practical skills acquisition of final year medical students in a Nigerian medical school

BACKGROUND/OBJECTIVE Young medical graduates undertaking their housemanship are naturally expected to demonstrate reasonable competence in basic practical skills. Failure to do this may not only be a source of anxiety to the doctor but also potentially dangerous to the patient. The objective was to assess the level of exposure of final year medical students of a Nigerian medical school to basic practical skills. MATERIALS AND METHODS This is a descriptive cross-sectional study. Structured questionnaires were distributed to a set (all) of 86 final year medical students of the University of Port Harcourt immediately after their last lecture in their final posting in medicine and surgery. The questionnaires listed some selected basic practical skills (e.g. phlebotomy, male urethral catheter insertion, etc.) that house officers are expected to be competent in. The students were asked to anonymously fill them and return same before leaving the lecture hall. RESULTS Of the 86 students, 84 completed and returned the questionnaires, giving a 97.7% response rate. No student had performed an arterial puncture for an arterial blood sample. Seventy-six students (90.5%) had not inserted a naso-gastric tube. Only 14 (16.7%) students had successfully inserted more than 10 intravenous canulae. A significant number, 38 (45.2%), had never inserted a urinary catheter (for male patients) nor had any experience with bag/mask skills. Majority, 59 (70.2%) had had some experience with intravenous antibiotics administration. Forty-one (48.7%) students had had 6 or more successful attempts at venous blood sampling. CONCLUSION The exposure level of final year medical students to basic practical skills was low.

Acute abdominal conditions in people with sickle cell disease: A 10-year experience in Port Harcourt, Nigeria

BACKGROUND Abdominal crises (vaso-occlusive) are not infrequent in patients with sickle cell anemia. They usually present as acute abdomen. These patients none the less present with other causes of acute abdomen like others without hemoglobinopathy. Six cases of surgical acute abdomen in sickle cell disease patients treated in the University of Port Harcourt Teaching Hospital (UPTH) are presented. MATERIALS AND METHODS Six sickle cell anaemia patients presenting with acute abdominal conditions from 1999 to 2008 (inclusive) in the University of Port Harcourt Teaching Hospital were studied retrospectively (two patients) and prospectively (four patients). After initial resuscitation, appropriate surgical procedures, namely, appendicectomy (2), cholecystectomy (1), open drainage of splenic abscess (1), and release of adhesive band (1) were performed. RESULTS Six cases were treated (female/male ratio 2:1). Four patients were in the 11-20 year age group. Two patients had appendicectomy and two presented with acute cholecystitis/cholelithiasis, one of whom had open cholecystectomy. One young girl had drainage of splenic abscess and a 42-year-old male had division of obstructive adhesive band at laparotomy. There were two complications, namely, postoperative haemorrhage (in cholecystectomy patient) and acute chest syndrome (in one appendicectomy patient). These were successfully managed with blood transfusion and antibiotic/oxygen therapy, respectively. There was no mortality. CONCLUSION Sickle cell anaemia patients are not exempt from acute abdominal conditions requiring surgery. A high index of suspicion coupled with repeated clinical examination is needed for early diagnosis and appropriate treatment.

Uribag drain as a versatile closed tube drain : a pilot study

The use of drains in surgery has been well documented in the literature for the decompression of collections of serosanguinous and pancreatic fluid, bile or purulent discharge. Access to proper drains such as Penrose or Redivac in our environment is often difficult, if not impossible. The dearth of these surgical drains has given rise to the quest for alternatives. An experience with the use of a uribag tube as drain is presented.

Phaeochromocytoma: Is it that uncommon?

Background: Phaeochromocytoma has been described as a rare condition in the literature. Aim: This study aims to present cases of phaeochromocytoma seen at the University of Port Harcourt Teaching Hospital (UPTH) over a period of 6 years (2003–2008). Methods: All patients that presented with phaeochromocytoma within the study period were included in the study. Data were collected from hospital records and presented as case series. Results: Five cases of phaeochromocytoma seen at the UPTH between 2003 and 2008 form the subject of the retrospective report. There were three males and two females, and their ages were 40, 28, 23, 37 and 11, respectively. Four of the resected specimen were benign in histology while one was malignant. Mortality was recorded in only one patient. Conclusion: Having seen five cases of a condition that is reported as rare within a period of 5 years raises the question as to whether phaeochromocytoma is as rare as is generally recorded.

Ileosigmoid knotting in patients under 25 years of age: A report of two cases

INTRODUCTION Ileosigmoid knotting is a rare cause of acute abdomen with high morbidity and mortality. Its diagnosis is infrequently made before surgery because of its varying ways of presentation and rarity. PRESENTATION OF CASE The first was a 21-year-old male who presented with a history of sudden generalized abdominal pain and progressive abdominal distension. He was pale and severely dehydrated. His extremities were cold and clammy. His pulse rate was 110 per minute and blood pressure was 90/50 mmHg. The second case was 20-year-old male who presented with similar symptoms as above. He was not pale but mildly dehydrated. His pulse rate was 92 per minute and blood pressure 110/70 mmHg. Both patients were resuscitated and had exploratory laparotomy a few hours after presentation. The first patient was found to have ileosigmoid knotting with gangrenous sigmoid colon and terminal ileum. He had Hartmanns procedure and right hemicolectomy with ileo-transverse anastomosis. The second patient was found to have ileosigmoid knotting with viable loops of bowel. He had careful detorsion, sigmoidectomy with primary anastomosis. Both patients’ have good outcome. DISCUSSION This is to report two cases of ileosigmoid knotting in two male patients aged 21 and 20 years, respectively, with the hope of increasing awareness. CONCLUSION Ileosigmoid knotting though more common in fourth or fifth decade of life, can also occur in the 2nd decade. Early diagnosis, careful resuscitation and skilful surgical intervention will improve outcome.

Acute Appendicitis Masquerading as Acute Scrotum A Case Report

Acute appendicitis presents typically with periumbilical pain that in a few hours settles at the right lower quadrant of the abdomen. Atypical presentations are common but association with acute scrotum is an extreme rarity. A 30-year-old fisherman presented at a rural medical facility with a 2-day complaint of severe pain at the right hemiscrotum followed about 24 hours later with mild diffuse abdominal pain. There was associated mild fever and nausea but no vomiting. There were no urinary symptoms and no recent sexual exposure. Initial physical examination revealed mild generalized tenderness worse at the right lower quadrant but the scrotum was not remarkable, and cremasteric sign was negative. He was admitted as a case of acute abdomen for close observation. Abdominal and scrotal ultrasound scan were normal. By the second day of admission, pain became marked at the right lower abdomen with associated vomiting. There was also marked tenderness at the right lower quadrant with rebound. A diagnosis of acute appendicitis was thus made and appendicectomy done after proper workup. The abdominal and scrotal pain stopped after surgery and the patient was discharged on the seventh postoperative day. Patients with unusual abdominal and scrotal pain should be admitted and closely observed and evaluated to prevent unnecessary scrotal exploration or negative appendicectomy.