Saima Nazir

Relapse of acute myeloid leukemia presenting as acute otitis media

A 26-year-old female was diagnosed with acute myeloid leukemia (AML-M2 subtype with normal cytogenetics) 2 years previously. She was induced with conventional 3 : 7 induction chemotherapy (daunorubicin; cytosine arabinoside) and consolidated with three high doses of cytosine arabinoside. After chemotherapy, the patient remained in remission for 1.5 years. A written informed consent was obtained from her for publishing her report. The patient presented to us with a purulent discharge from her left ear of 1 month duration. She also gave a history of occasional headaches …

Artery to Cystic Duct: A Consistent Branch of Cystic Artery Seen in Laparoscopic Cholecystectomy

Uncontrolled arterial bleeding during laparoscopic cholecystectomy is a serious problem and may increase the risk of bile duct damage. Therefore, accurate identification of the anatomy of the cystic artery is very important. Cystic artery is notoriously known to have a highly variable branching pattern. We reviewed the anatomy of the cystic artery and its branch to cystic duct as seen through the video laparoscope. A single artery to cystic duct with the classical “H-configuration” was demonstrated in 161 (91.47%) patients. This branch may cause troublesome bleeding during laparoscopic dissection in the hepatobiliary triangle. Careful identification of artery to cystic duct is helpful in the proper dissection of Calots triangle as it reduces the chances of hemorrhage and thus may also be helpful in prevention of extrahepatic biliary radical injuries.

Prolapse of a feeding jejunostomy

Feeding jejunostomy is an excellent option for nutritional support.1 A 19-year-old female reported to the emergency department with a history of corrosive ingestion. After initial resuscitation, a Stamm feeding jejunostomy was created for nutritional support. Feeds were started on the 3rd postoperative day and she tolerated them well. She reported back to the emergency 27 days after the procedure with prolapse of the feeding jejunostomy (Figure 1) that had occurred the day before when the patient was coughing. the prolapsed part was edematous and did not show any features of ischemia or ulceration. the patient was resuscitated and hypertonic saline soaked packs were kept over the prolapsed gut. However all these conservative attempts at reducing the prolapse proved futile. emergency surgery was performed. After a formal laparotomy, the prolapse was reduced and the feeding tube was removed. the enterotomy of the feeding tube was closed and a new Stamm jejunostomy was created distal to the original one. the patient is on followed up regularly and was doing well at the time or writing. Prolapse of feeding jejunostomy in association with changing of the feeding tube has been reported previously,2 but in our case it occurred spontaneously without any intervention. Other unusual complications that have been reported with feeding jejunostomy are knotting and enteral migration of the tube.3,4 Once such complications occur, we believe that it is prudent to revise the jejunostomy as conservative methods usually fail.

Rectal perforation due to a lost toothbrush.

Ann Saudi Med 2013 September-October www.annsaudimed.net 514 Inserted rectal foreign bodies are generally seen in mentally challenged or sexually deviated persons and often pose a challenging diagnostic and therapeutic dilemma.1 Retained rectal foreign bodies may present with perforation, obstruction, or bleeding.1 A 54-year mentally challenged female presented to the surgical emergency with the features of subacute intestinal obstruction with a lump palpable in the left iliac fossa and normal rectal examination. All attempts to manage the patient conservatively ultimately ended in futility. A contrast-enhanced computed tomography abdomen was ordered, and, to our surprise, it revealed the presence of a tooth brush within the rectum with free air pockets and distended gut loops around it (Figure 1). The patient underwent an emergent exploratory laparotomy. Exploration revealed matted gut loops and omentum in the left iliac fossa with minimal fecal contamination of the peritoneal cavity. After the adherent gut loops were separated, the tooth brush came into view. The tooth brush had perforated the rectal wall, and a part of it was lying outside the rectum (Figure 2). The tooth brush was retrieved, and as the surrounding rectal wall was not healthy, a Hartmann procedure was done. Although rectal foreign bodies have been reported in all ages and ethnicities, they are most commonly seen in men in the age group of 30 to 50 years. A variety of objects have been described in the published reports, and the list includes vibrators, dildos, cucumbers, apples, light bulbs, knives, nails, bottles, utensils, drug packets, and so on.1 Although a toothbrush present as a foreign body in the rectum has been previously reported,2 but such a presentation as has been reported in this study is the first of its kind. An important problem encountered in the management of rectal foreign bodies is the delay in presentation, as many patients may be embarrassed and conceal the history. As our patient was mentally challenged, we were not able to extract the proper history from her, Rectal perforation due to a lost toothbrush

A 40-year old obese female with altered sensorium

Ann Saudi Med 27(4) July-August 2007 www.saudiannals.net 301 A 40-year old obese female was admitted with altered sensorium, a history of vomiting and documented hyponatremia followed by fluctuating encephalopathy and a deep coma state. She was initially managed at a peripheral health center where her serum sodium was 98 mEq/L. She was treated for severe hyponatremia (duration of hyponatremia and rate of correction not known) with a slight improvement noticed by her family members initially. The patient was managed inititally at a primary health center by a primary care physician with slight improvement but soon developed fluctuating encephalopathy and was shifted to our medical center. On admission, the patient was still in a stuperous state with spontaneous guttural vocalization only and no active movement of her limbs. On examination, the patient had asymmetrical extrapyramidal signs–more on the right side compared to the left. The patient had normal pupillary reflexes and A 40-year old obese female with altered sensorium