Rauf A. Wani

Nontraumatic terminal ileal perforation.

BackgroundThere is still confusion and controversy over the diagnosis and optimal surgical treatment of non traumatic terminal ileal perforation-a cause of obscure peritonitis.MethodsThis study was a prospective study aimed at evaluating the clinical profile, etiology and optimal surgical management of patients with nontraumatic terminal ileal perforation.ResultsThere were 79 cases of nontraumatic terminal ileal perforation; the causes for perforation were enteric fever(62%), nonspecific inflammation(26%), obstruction(6%), tuberculosis(4%) and radiation enteritis (1%). Simple closure of the perforation (49%) and end to side ileotransverse anastomosis(42%) were the mainstay of the surgical management.ConclusionTerminal ileal perforation should be suspected in all cases of peritonitis especially in developing countries and surgical treatment should be optimized taking various accounts like etiology, delay in surgery and operative findings into consideration to reduce the incidence of deadly complications like fecal fistula.

Promoter Methylation Status of DNA Repair Gene (hMLH1) in Gastric Carcinoma Patients of the Kashmir Valley

Cancer is a multi-factorial disease and variation in genetic susceptibility, due to inherited differences in the capacity to repair mismatches in the genome, is an important factor in the development of gastric cancer (GC), for example. Epigenetic changes, including aberrant methylation of 5/CpG islands in the promoter regions of mismatch repair (MMR) genes like hMLH1, have been implicated in the development of various types of GC. In the present study we evaluated the role of hMLH1 promoter hypermethylation in Kashmiri GC patients and controls, and assessed correlations with various dietary and lifestyle factors. The study included 70 GC patients (56 males and 14 females; age (mean ± S.D) 50 ± 11.4 years). Distinction between methylated and unmethylated was achieved with MS-PCR and DNA band patterns. The Chi-square test was applied to assess the risk due to promoter hypermethylation. We found a strikingly high frequency of promoter hypermethylation in GC cases than in normal samples (72.9% (51/70) in GC cases vs 20% (14/70) in normal samples (p=0.0001). We also observed a statistically significant association between methylated hMLH1 gene promoter and smoking, consumption of sundried vegetables and hot salted tea with the risk of GC. This study revealed that hMLH1 hypermethylation is strongly associated with GC and suggested roles for epigenetic changes in stomach cancer causation in the Kashmir valley.

Secondary Tuberculosis of Breast: Case Report

Tuberculosis of breast is a rare disease which is difficult to differentiate from carcinoma of breast. The involvement of breast can be primary or secondary to some focus in body. A case of secondary tuberculosis of right breast in a 21-year-old female from Kashmir, India, is being reported. Presentation was as a painless discharging sinus of right breast. A tubercular foci of rib was the affecting source of disease. No other evidence of tuberculosis was present in the body. Resection of involved rib segment, along with the discharging sinus, was performed. The patient had antitubercular therapy for 9 months, with no recurrence seen in followup.

Spectrum of abdominal organ injury in a primary blast type

IntroductionAbdominal organ injury in a primary blast type is always challenging for diagnosis. Air containing abdominal viscera is most vulnerable to effects of primary blast injury. In any patient exposed to a primary blast wave who presents with an acute abdomen, an abdominal organ injury is to be kept in a clinical suspicion.AimStudy various abdominal organ injuries occurring in a primary type of blast injury.Material and methods: All those who had exploratory laparotomy for abdominal organ injuries after a primary blast injury for a period of 10 years from January 1998 - January 2008 were included in this retrospective study.ResultsTotal 154 patients had laparotomy for abdominal organ injuries with a primary blast type of injury. Small intestine was damaged in 48 patients (31.1%) followed by spleen in 22.7% cases. 54 patients (35.06%) had more than one organ injured. Liver laceration was present in 30 patients (19.48%). Multiple small gut perforations were present in 37 patients (77.08%). Negative laparotomy was found in 5 patients (3.24%) whereas 3 (1.94%) had re-exploration. Mortality was present in 6 patients (3.89%).ConclusionsPrimary blast injury causes varied abdominal organ injuries. Single or multiple organ damage can be there. Small intestine is commonest viscera injured. Laparotomy gives final diagnosis.

Closure of the Common Duct -Endonasobiliary Drainage Tubes vs. T Tube: A Comparative Study

For the last century T tube drainage of the bile duct has remained standard practice following choledochlithotomy. It vents the biliary tree, provides route for cholangiography and management of residual stones. However, T tubes are associated with significant complications. This retrospective study compared the use of Endonasobiliary drainage tubes and the T tube in 66 patients who underwent open choledocholithotomy for effectiveness and complications. Both groups were statistically comparable. Only 15.15% patients in the Endonasobiliary drainage group, while 45.45% patients in the T tube group developed complications. Severe complications such as biliary peritonitis and intraperitoneal collections were noted only in the T tube group. The Endonasobiliary drainage tube was removed significantly earlier and patients from this group were discharged earlier as compared to those in the T tube. The Endonasobiliary drainage tube is as effective as the T tube in postoperative biliary drainage and allows cholangiograms to be performed. Its use is associated with less complications and it can be removed safely earlier than the T tube. Thus patients have a shorter time with tubes and can be discharged home earlier.

Isolated small bowel mesentery injury after steering wheel trauma

Background Isolated small gut mesentery injury after blunt abdominal trauma from the steering wheel in road traffic accidents is rare. These are always challenging to diagnose and pose a diagnostic dilemma. Objectives To study the pattern of small gut mesenteric injury by steering wheel blunt abdominal trauma in road traffic accidents in patients who had laparotomy. Patients and Methods A 10-year retrospective study was done to study isolated small gut mesentery injury. Results All patients who had isolated mesenteric small gut injury were males. Jejunal mesentery was involved in 13 whereas 4 had ileal mesentery injury. Tear were longitudinal or transverse. Conclusions Isolated small mesentery injury after blunt abdominal trauma from the steering wheel in road traffic accidents is rare. Tears are either longitudinal or transverse. Suture repair is to be done. Delay in reaching hospital or reaching the diagnosis could lead to morbidity and mortality. Isolated mesenteric injury should be considered in any patient with blunt abdominal trauma from steering wheel injury with no evidence of any solid organ injury in unstable patients.

Profile and Outcome of Violence Related Injuries of Patients during Civilian Unrest in a Conflict zone

Background: Violence is an intrinsic phenomenon to a class based society which is inherently unequal and oppressive. In the episodes of contemporary violence civilians witness events such as shooting, killing or physical assault and get inadvertently entrapped. Methods: In a hospital based study, during 2010, the hospital received 630 violence related civilian patients of which 393 were admitted. Results: Of the 393 patients admitted 157 (39.94%) had head injuries, 131 (33.33%) limb injuries, 28 (7.12%) chest injuries and 24 (6.10%) abdominal injuries. Forty-three (10.94%) patients had multisystem injuries. Most of the patients had history of physical assault. Of all the injured admitted 159 (40.4%) were having major injuries of which 59 (37.10%) comprised head injuries, 24 (15.09%) chest trauma, 17 (10.69%) abdominal trauma and 51 (32.07%) limb injuries. Of the 393 patients admitted, 324 (82.44%) recovered fully, 10 (2.54%) were disabled, 22 (5.59%) were referred to other hospitals and 28 patients (7.12%) expired. Most of the injured were in the age group 13-24 years. Conclusion: The study was done as part of critical care audit towards capacity building exercise for establishment of comprehensive healthcare delivery infrastructure. Social, economic and public health aspects of violence are discussed in detail.

Encountering Meckel's diverticulum in emergency surgery for ascaridial intestinal obstruction

BackgroundMeckels diverticulum is the most common congenital anomaly of the gastrointestinal tract. In children with intestinal ascariasis, the diverticulum remains asymptomatic or rarely the Ascaris lumbricoides may lead to its complications in the presence of massive intestinal roundworm load. Given that preoperative diagnosis is seldom carried out, when Meckels diverticulum is found at laparotomy for obstructive intestinal complications of roundworm, the diverticulum should be removed as complications may occur at any time. The aim of this study was to describe the findings of concomitant presence of Meckels diverticulum who had surgical intervention in symptomatic intestinal ascariasis in children.MethodsA retrospective case review study of 14 children who had surgical intervention for symptomatic intestinal ascariasis having the presence of concomitant Meckels diverticulum was done. The study was done at SMHS Hospital Srinagar, Kashmir.ResultsA total of the 14 children who had ascaridial intestinal obstruction with concomitant presence of Meckels diverticulum were studied. Age of children ranged from 4-12 years, male:female ratio was 1.8:1. Nine patients had asymptomatic Meckels diverticulum, whereas 5 patients with symptomatic signs were found in the course of emergency surgery for ascaridial intestinal obstruction.ConclusionMeckels diverticulum in intestinal ascariasis may pursue silent course or may be accompanied with complications of the diverticulitis, perforation or the gangrene. Incidental finding of the Meckels diverticulum in the intestinal ascariasis should have removal.

Jejunogastric intussusception presenting as tumor bleed

Jejunogastric intussusception (JGI) is a rare but serious complication of previous gastrectomy or gastrojejunostomy, and a delayed diagnosis can lead to catastrophe. It can present as hematemesis, and an endoscopist aware of the condition can diagnose it early. We present a case of JGI presenting as hematemesis and diagnosed as tumor bleed on endoscopy. Diagnosis of JGI was confirmed on laparotomy, gangrenous efferent limb was resected and a fresh gastrojejunostomy performed.

Subcutaneous internal lateral sphincterotomy (SILS) versus nitroglycerine ointment in anal fissure: a prospective study.

AIM To compare the results of subcutaneous internal lateral sphincterotomy under local anesthesia and nitroglycerin ointment treatments in acute and chronic anal fissures. METHODS This was a comparative, prospective study of 340 patients of acute and chronic anal fissure. The patients voluntarily opted either for the surgical procedure under local anesthesia, or the nitroglycerin treatment. All the patients were followed with regular checkups and complaints were documented. RESULTS Except for 1.75% patients having bleeding/hematoma formation, and with a dropout of 2.60% patients, no failure, recurrence or long term complications like incontinence, were observed in patients who underwent subcutaneous internal lateral sphincterotomy after a mean follow up of 28 months. With surgical treatment pain, bleeding per rectum and constipation showed significant improvement as compared to nitroglycerin treatment. Fissure healing was 100% in surgical group as compared to 56.90% in medical group (P=0.000, odds ratio=344.6). Nitroglycerin was equally effective in acute and chronic fissures (P=0.096). CONCLUSION Subcutaneous internal lateral sphincterotomy under local anesthesia is more curative, easy and safe, in the hands of a beginner as well as an experienced surgeon, with highest patient satisfaction, and should be considered as the first line of therapy in both chronic and resistant/recurrent acute anal fissures.