Cholecystitis Without Gallstones

10.1155/1990/89848HPB Surgery2283-10

Clinical Profile and Genetic studies in Recurrent Acute Pancreatitis : A Five Year Study.

INTRODUCTION : Numerous studies have been conducted on acute and chronic pancreatitis , but only few have focused on recurrent acute pancreatitis(RAP). Recurrent acute pancreatitis may be due to biliary disease, alcohol, metabolic factors (hypercalcemia, hypertriglyceridemia), drugs, trauma, sphincter of Oddi dysfunction, pancreas divisum and pancreatic carcinoma. Evaluation fails to detect the cause in 10 – 30% of patients , and these patients are labelled as idiopathic recurrent acute (IAP) pancreatitis(IRAP). Further evaluation and therapy is important because more than 50% of untreated patients with RAP experience recurrent episodes that can lead to chronic pancreatitis Mutations in cationic trypsinogen gene (PRSS1) , SPINK1 gene ,cystic fibrosis transmembrane conductance regulator gene (CFTR) and Cathepsin B gene have been demonstrated in acute and chronic pancreatitis(3-6). It is possible that genetic mutations may be the cause of pancreatitis in patients now labelled as Idiopathic Recurrent Pancreatitis. Few patients with gall stones or alcoholism develop RAP. It is therefore conceivable that genetic mutations enhance susceptibility to RAP in patients with other predisposing factors. RAP may be a complex disease process resulting from an interplay of genetic susceptibilities and environmental factors. AIMS AND OBJECTIVES : 1. To study the clinical profile, efficacy of medical / endoscopic therapy and outcome of recurrent acute pancreatitis. 2. To assess the prevalence of genetic mutations in recurrent acute pancreatitis. CONCLUSIONS: Biliary disease (stone (20%); sludge / microlithiasis (28%) is the most common cause of recurrent acute pancreatitis (RAP). Determining etiology is important to assess the progressive nature of the disease . The extent of evaluation impacts the frequency with which an etiology can be found. Bile for microliths and ERCP should therefore be part of evaluation of RAP as these detect the etiology in 1/3rd of patients. Distribution of etiological factors was similar in East , South and North India. After extensive evaluation including ERCP and testing bile for microliths , a cause for RAP could not be detected in 18% of patients. Genetic mutations do not play a major role in the etiopathogenesis of RAP. Further studies with larger sample size needs to be done. Severe pancreatitis (14%) was predominantly seen in biliary and Idiopathic RAP. Patients with biliary microlithiasis responded well to treatment with UDCA and biliary sphincterotomy. Patients with pancreas divisum responded well to accessory papilla sphincterotomy. Some patients labeled as Idiopathic RAP may respond to empiric biliary sphincterotomy as they may have occult biliary microlithiasis or sphincter of Oddi dysfunction. Patients (38%) labeled as Idiopathic RAP responded to empiric trial of pancreatic enzymes. Large controlled trials are required to determine the role of pancreatic enzymes , antioxidants or octreotide in therapy of Idiopathic RAP. Does Idiopathic RAP really exist ? An etiology was obtained in 93% of patients after extensive evaluation , empiric biliary sphincterotomy in Idiopathic RAP and development of chronic pancreatitis on follow up.It is possible that on further follow up , the 7 % of patients may progress to chronic pancreatitis. Follow up of patients with idiopathic RAP is necessary as some may progress to chronic pancreatitis

Clinical study and management of Obstructive Jaundice

INTRODUCTION: Jaundice is a frequent manifestation of biliary tract disorders and the evaluation and management of obstructive jaundice is a common problem faced by the general surgeon. Obstructive jaundice is strictly defined as a condition occurring due to a block in the pathway between the site of conjugation of bile in liver cells and the entry of bile into the duodenum through the ampulla. The block may be intrahepatic or extra hepatic in the bile duct. Despite the technical advances, the operative modes of management of obstructive jaundice were associated with very high morbidity and mortality. Yet, during the last decade significant advances have been made in our understanding with regard to the pathogenesis, diagnosis, staging and the efficacy of management of obstructive jaundice.. Obstructive jaundice of varied etiology is one of the cause s of admission to hospitals across North Karnataka. To diagnose the cause, site of obstruction and management of a case of surgical jaundice is indeed a challenging task for the surgeon. Hence, a comprehensive study of the etiology, clinical presentation a nd management of obstructive jaundice is of paramount importance in the appropriate management of these patients. OBJECTIVES: • To study the clinical history and presentation of obstructive jaundice. • To study the various causes and sites of obstruction of the biliary tree. • To study the different modalities of treatment of obstructive jaundice. METHODOLOGY: Source of Data: Patients admitted to the institute of General Surgery at the Rajiv Gandhi government general Hospital, Chennai were taken up for the study. Numbers of cases studied were 50. Method of Collection of Data: After admission to RGGGH, a detailed clinical history and examination of the patient was done. Relevant investigations were undertaken to make a diagnosis. Patients were assessed preoperatively for the fitness for surgery and later subjected to curative or palliative surgery depending on the stage of the disease and general condition of the patient. The resected tissue was subjected to histopathological examination. Postoperatively, patients’ condition was assessed and complications were documented. Photographic documentation has been done wherever possible. Inclusion criteria: • Age – More than 12 years. • Patients proved to have obstructive jaundice by any investigative modality during the study period from April 2004 to March 2005. Exclusion criteria: • Age less than 12 years, • Medical jaundice, • Cases of obstructive jaundice who are unfit for interventional treatment. Statistical methods: Chi-square and fisher exact test have been used to find the significance of proportion of symptoms &signs between benign and malignant cases. Student t test has been used to find the significance of mean difference of lab parameters between benign and malignant cases. The odds ratio has been used to find the strength of relationship between symptoms & signs of benign and malignant cases. If p value was <0.05 the probability was considered to be statiscally significant. RESULTS AND OBSERVATIONS: A Prospective clinical study consisting of 50 cases of Obstructive jaundice was undertaken to investigate the pattern of clinical presentation & lab parameters to study the cause of obstructive jaundice and the different modes treatment adopted. CONCLUSION: Common presentation of surgical jaundice is jaundice. Palpable GB indicates the etiology to be malignant. Common cause for surgical jaundice is CBD calculi. USG remains the cheapest, safest and mo st reliable diagnostic tool in the management of surgical jaundice. Open exploration of CBD under experienced hands is a good treatment modality in the management of obstructive jaundice. In malignancies, early detection and staging and proper selection of the patient are more important to gain benefit from resection of tumour, whereas late presentation and those patients not suitable for resection had good improvement in quality of survival with palliative surgery. Improving deranged LFT, correction of anaemia and hepatorenal problem improves the surgical results (morbidity and mortality)

Quality of life of patients living with a stoma and association with the socio-demographic factors

Introduction: Stoma formation is a lifesaving surgery to help in the excretion of feces or urine from the body. Previous studies showed that stoma could compromise the patient’s quality of life (QoL), and this issue was associated with their background characteristics. This study aimed to assess QoL and association with the socio-demographic factors among the patients living with a stoma. Methods: A retrospective study was conducted in a teaching hospital in Pahang. Medical records starting from November 2018 until November 2020 were examined, resulting in 48 patients with stoma were selected. Telephone interviews using structured questionnaires were conducted to collect data on socio-demographic and QoL. Quality of Life Questionnaire for a Patient with an Ostomy (QoL-O) was used to measure the QoL of patients living with a stoma. The maximum score was 10, and the minimum score was 0. Result: 24 patients enrolled in this study (response rate = 50%). Their mean age was 56.8 (SD = 18.6) with 70.8% were men (n = 17) and 29.2% were women (n = 7). Almost all were Malay (95.8%) and 79.2% completed secondary school and above. Only 20.8% were employed, and 79.2% were unemployed or retired. About 58.3% had ileostomy, and 41.7% colostomy. The overall mean score of QoL was 7.1 (SD = 1.0). A significant association was only found between QoL and employment status (p = 0.025). Those employed had higher scores on QoL (8.4, IQR 1.0) compared to the retired group (7.1, IQR 1.0) and the unemployed (6.3, IQR 1.0). Conclusion: Most of the patients living with a stoma in this study had a moderate QoL, which was mainly associated with their employment status. Further research with a greater number of patients is needed to determine their QoL as well as to consider other potential factors that may influence their perspectives on QoL