Sujit Kumar

Spontaneous Gallbladdre Perforation: A case series

Background: Gallbladder is rarely injured as it is embedded in the liver and well protected by ribcage. Gallbladder perforation is a rare complication of acute calculus cholecystitis. Spontaneous gallbladder perforation is even rarer. Case Series: We present our experience of 4 cases of spontaneous gallbladder perforation. The patients were mostly males (3:1) with age ranging from 42-64 years. All the patients presented with abdominal pain, distension, ileus and fever ranging from 2-5 days duration. There was no prior history of biliary colic. Examination revealed abdominal tenderness and ileus. Abdominal radiographs showed multiple air-fluid levels and no pneumoperitoneum. Sonography and CT scan of abdomen revealed pericholecystic fluid, intra-abdominal collection with no evidence of gallstones. Provisional diagnosis was peritonitis in 3 and acute pancreatitis in one case. Image guided abdominal paracentesis yielded bilious fluid. In view of lack of clinical improvement and aspiration of bilious content all the patients were subjected to laparotomy. Gallbladder perforation in fundus region without stones and intra-abdominal bile collection was noted in all the patients. Cholecystectomy with peritoneal lavage and abdominal drainage was performed in all cases. Postoperative course was uneventful except wound infection in 2 cases. Histopathology report revealed features of acute cholecystitis in 2 and acute on chronic cholecystitis in the remaining 2 patients. Conclusion: Diagnosis of spontaneous gallbladder perforation should be suspected in middle aged patients who present with acute abdomen but does not have classical signs of peritonitis and in whom paracentesis has yielded bilious fluid.

Choledochal cyst: their clinical presentation, diagnosis and treatment in central Nepal: a retrospective study

Background: Choledochal cyst is a rare congenital malformation involving the cystic dilatation of intrahepatic or extra-hepatic or both bile duct .The estimated incidence is one in 1000 live birth in Asian population with female to male ratio 3:1. Objectives: To study the clinical presentations, diagnostic modalities, treatment and outcome of choledochal cyst in College of Medical Sciences, Bharatpur, Nepal Methods: A retrospective review of the records of all the patients who were diagnosed as choledochal cyst and underwent medical or operative intervention in our hospital in the period of January 2013- January 2015. Results: We have analyzed ten cases of choledochal cyst. We found most common age group of presentation of choledochal cyst was 6-10 yr with female preponderance (70%). Most common presenting symptom was pain abdomen (100%) followed by jaundice (50%). However classical triad of abdominal pain, jaundice, and an abdominal mass was not seen in any of the cases. Ultrasonography was found to be 100 % accurate in diagnosis of choledochal cyst. Todani type I cyst was the most common type. Nine out of ten cases underwent complete cyst excision with cholecystectomy and Roux-en-Y hepaticojejunostomy without any major complication. Malignancy was not seen in any patients. Conclusion: Choledochal cyst is a rare disease. Most common age group of presentation is 6-10 yrs. Pain abdomen is the most common clinical presentation. Ultrasonography is usually the first examination and is very sensitive for diagnosis of choledochal cyst. Complete cyst excision, cholecystectomy and internal drainage is the treatment of choice.