Biliary atresia

Biliary atresia (BA) is a rare disease characterised by a biliary obstruction of unknown origin that presents in the neonatal period. It is the most frequent surgical cause of cholestatic jaundice in this age group. BA occurs in approximately 1/18,000 live births in Western Europe. In the world, the reported incidence varies from 5/100,000 to 32/100,000 live births, and is highest in Asia and the Pacific region. Females are affected slightly more often than males. The common histopathological picture is one of inflammatory damage to the intra- and extrahepatic bile ducts with sclerosis and narrowing or even obliteration of the biliary tree. Untreated, this condition leads to cirrhosis and death within the first years of life. BA is not known to be a hereditary condition. No primary medical treatment is relevant for the management of BA. Once BA suspected, surgical intervention (Kasai portoenterostomy) should be performed as soon as possible as operations performed early in life is more likely to be successful. Liver transplantation may be needed later if the Kasai operation fails to restore the biliary flow or if cirrhotic complications occur. At present, approximately 90% of BA patients survive and the majority have normal quality of life

GUIDELINES FOR THE MANAGEMENT OF HAEMODYNAMICALLY STABLE PATIENTS WITH STAB WOUNDS TO THE ANTERIOR ABDOMEN

Clinical practice guidelines have been shown to improve the delivery of care. Anterior abdominal stab wounds, although uncommon, pose a challenge in both rural and urban trauma care. A multidisciplinary working party was established to assist in the development of evidence-based guidelines to answer three key clinical questions: (i) What is the ideal prehospital management of anterior abdominal stab wounds? (ii) What is the ideal management of anterior abdominal stab wounds in a rural or urban hospital without an on-call surgeon? (iii) What is the ideal emergency management of stable patients with anterior abdominal stab wounds when surgical service is available? A systematic review, using Cochrane method, was undertaken. The data were graded by level of evidence as outlined by the Australian National Health and Medical Research Council. Stable patients with anterior abdominal stab wounds should be transported to the hospital without delay. Any interventions deemed necessary in prehospital care should be undertaken en route to hospital. In rural hospitals with no on-call surgeon, local wound exploration (LWE) may be undertaken by a general practitioner if confident in this procedure. Otherwise or in the presence of obvious fascial penetration, such as evisceration, the patient should be transferred to the nearest main trauma service for further management. In urban hospitals the patient with omental or bowel evisceration or generalized peritonitis should undergo urgent exploratory laparotomy. Stable patients may be screened using LWE. Abdominal computed tomography scan and plain radiographs are not indicated. Obese and/or uncooperative patients require a general anaesthetic for laparoscopy. If there is fascial penetration on LWE or peritoneal penetration on laparoscopy, then an urgent laparotomy should be undertaken. The developed evidence-based guidelines for stable patients with anterior abdominal stab wounds may help minimize unnecessary diagnostic tests and non-therapeutic laparotomy rates