Biomedical subjects
Publications and source records attributed to A Sachdev.
A 46 year old male inadvertently consumed 500 ml of glycerol and presented with altered sensorium, focal neurologic signs and generalised seizures. He was managed conservatively and recovered fully within 48 hours. The case highlights the rare presentations of overdosage and neurologic effects with glycerol, an otherwise safe drug used in neurology.
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Reflex epilepsy is the commonest form of epilepsy in which seizures are provoked by specific external stimulus. Photosensitive reflex epilepsy is provoked by environmental flicker stimuli. Video game epilepsy is considered to be its variant or a pattern sensitive epilepsy. The mean age of onset is around puberty and boys suffer more commonly as they are more inclined to play video games. Television set or computer screen is the commonest precipitants. The treatment remains the removal of the offending stimulus along with drug therapy. Long term prognosis in these patients is better as photosensitivity gradually declines with increasing age. We present two such case of epilepsy induced by video game.
Hypokalaemic paralysis is a relatively uncommon but potentially life-threatening clinical syndrome. If recognised and treated appropriately, patients recover without any clinical sequellae. The syndrome of hypokalaemic paralysis represents a heterogeneous group of disorders characterised clinically by hypokalaemia and acute systemic weakness. Most cases are due to familial or primary hypokalaemic periodic paralysis; sporadic cases are associated with numerous other conditions including barium poisoning, hyperthyroidism, renal disorders, certain endocrinopathies and gastrointestinal potassium losses. The age of onset, race, family history, medications, and underlying disease states can help in identifying the cause of hypokalaemic paralysis. Initial therapy of the patient with hypokalaemic paralysis includes potassium replacement and search for underlying aetiology. Further management depends on the aetiology of hypokalaemia, severity of symptoms, and duration of disease. This review presents the differential diagnosis for hypokalaemic paralysis and discusses management of the syndrome.
BACKGROUND: Varices can develop in and around the bile duct in the presence of portal hypertension, especially when it is caused by extrahepatic portal vein thrombosis. The term 'portal biliopathy' is used to describe changes in the bile duct due to these varices, which may cause bile duct obstruction. This paper reviews experience of the surgical management of patients with symptomatic portal biliopathy. METHODS: Nine patients with extrahepatic portal vein obstruction with symptomatic portal biliopathy. were reviewed retrospectively. RESULTS: Eight patients presented with jaundice, two had abdominal pain and one had recurrent cholangitis. Endoscopic retrograde cholangiography revealed abnormality of the bile duct wall, with stricture in eight patients and bile duct calculi in two. Portasystemic shunting relieved jaundice in five of seven patients, and in two a second-stage hepaticojejunostomy was required. CONCLUSION: Symptomatic biliary obstruction in patients with extrahepatic portal hypertension may be relieved by a portasystemic shunt. Rarely biliary bypass may be required and is rendered safer by previous portasystemic shunting to decompress the pericholedochal varices. A direct approach to the biliary tract without a preliminary shunt may be hazardous and is frequently unnecessary.
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BACKGROUND: Local complications of pancreatic necrosis may occur after surgery, but when they occur spontaneously render surgical treatment more hazardous and impair prognosis. METHODS: A retrospective review was carried out of 83 patients who underwent surgery for pancreatic necrosis from 1988 to 1995, to determine the incidence, type, treatment and outcome of locoregional complications caused by pancreatic necrosis associated with acute pancreatitis. RESULTS: Seventeen patients (20 per cent) were identified to have intra-abdominal complications with pancreatic necrosis either before operation or at the time of surgery. The majority of patients had a delay in intervention (mean 46 days). At presentation ten of the 17 patients had one or more organ system failures. Fourteen patients had gastrointestinal tract involvement, two had involvement of the biliary tract and one patient had a splenic rupture. Six patients died. CONCLUSIONS: In patients with pancreatic necrosis, development of locoregional complications is associated with a high mortality rate. The presence of gastrointestinal bleeding, peritonitis, jaundice or pneumoperitoneum in such patients suggests the presence of a complication of the necrotic process and should prompt early intervention. Early referral of patients with severe acute pancreatitis to specialized units may reduce the risk of locoregional complications.
Jaundice in patients of advanced carcinoma of the gallbladder requires palliation for the distressing symptoms of pruritus and cholangitis. Intrahepatic segment III duct cholangiojejunostomy is a means for alleviating the obstruction with malignant porta block. The authors reviewed their experience with this procedure in 48 patients of carcinoma of the gallbladder. All patients had jaundice; pruritus was present in 44 (92%) and cholangitis in 14 (29%). The level of obstruction was determined preoperatively by percutaneous transhepatic cholangiography. In 32 patients the block was below the level of the bifurcation of the right and left ducts, and 16 patients had a block involving the confluence, isolating the two lobes of the liver. Following segment III cholangiojejunostomy, pruritus was relieved in all and cholangitis in 86% of patients. At the end of 6 weeks a significant fall in serum bilirubin and alkaline phosphatase levels was seen with both types of hilar obstruction. Varying degrees of pain relief was also noted in 75% of patients. Segment III biliary bypass is an effective, one-time, reliable means of palliation for carcinoma of the gallbladder with hilar obstruction. Its efficacy appears to depend on the duration and depth of the jaundice and on the anatomy of the biliary ductal system in the left hemiliver rather than on the type of hilar obstruction.
BACKGROUND: Complications often follow if a choledochal cyst is treated simply by drainage, either internal or external. This study reviews 17 patients who had had previous cystoenterostomy (n = 9) or external drainage (n = 8) and who required reoperation and cyst excision. METHODS: The study was a retrospective review including ten women and seven men managed over 9 years. The indications for reoperation were stone formation (10 patients), pancreatitis (three), portal hypertension (two) and hepatic abscess (one); two patients were asymptomatic. RESULTS: Definitive surgery with cyst excision was possible in all patients who had previously had external cyst drainage and in seven of nine who had had previous cystoenterostomy. There were no deaths. Two postoperative biliary leaks and two duodenal fistulas resolved spontaneously. CONCLUSION: Excision of a choledochal cyst is possible and desirable even after a previous drainage operation. In severely ill patients with a complication of choledochal cyst, external drainage may be a preferable initial manoeuvre.
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PURPOSE: Segmental colonic tuberculosis commonly involves the ascending, transverse, or sigmoid colon. Rectal involvement in tuberculosis is uncommon and poorly characterized. This study describes the clinical presentation, endoscopic features, and outcome of isolated rectal tuberculosis. METHODS: Isolated rectal tuberculosis was defined as focal lesions of the rectum in the absence of radiologically demonstrable lesions in the small and large bowel on barium contrast studies. Diagnosis of rectal tuberculosis was based on characteristic endoscopic appearance of lesions, histopathologic features of tuberculosis in biopsy/ resected material, and response to antitubercular therapy. RESULTS: Eight patients with rectal tuberculosis were seen during a four-year period at our hospital. Hematochezia was the most common presenting feature (88 percent), followed by constitutional symptoms (75 percent) and constipation (37 percent). Rectal examination revealed a tight stricture within 10 cm of the anal verge in seven patients. Barium enema showed stricture of variable length, with focal areas of deep mucosal ulceration and increase in presacral space. Proctoscopic findings were tight stricture (7), nodularity with ulceration (6), and multiple aphthous ulcers (1). Granulomatous infiltration was detected in seven of eight patients in biopsy material obtained at endoscopy (6) or surgery (1). Cessation of hematochezia, resolution of constitutional symptoms, and weight gain were seen in all patients following treatment with antitubercular drugs. CONCLUSION: Our data suggest that tubercular involvement of rectum, although uncommon, is an important cause of rectal strictures in India. Response to antitubercular chemotherapy is uniformly good, and surgery is seldom required in these patients.
BACKGROUND: Serous effusions in chronic pancreatitis are infrequent but persistent. These occur usually as a consequence of internal pancreatic fistulae and commonly involve the pleural cavity or peritoneum. METHODS: To assess strategies in operative management, the records of 12 patients who underwent surgery for internal pancreatic fistula with underlying chronic pancreatitis were reviewed retrospectively. Seven patients had pancreatic ductal calculi. Three cases underwent external drainage. Three cases with leaking pseudocysts underwent cystojejunostomy-en-Y. Three cases with ductal dilatation or calculi underwent lateral pancreaticojejunostomy and three patients had caudal pancreatectomy for distal disease. RESULTS: Eight patients were completely controlled of all symptoms, with no sequelae. One case each had recurrent pancreatitis and ascites but did not require re-operation. There were two deaths: one with massive haematemesis and one with pre-existent multi-organ failure and sepsis. CONCLUSIONS: Pancreatic duct stones may be causally associated with internal pancreatic fistulae. Delineation of ductal anatomy and pathological aberrations of the pancreas, including determination of the leak site, was of paramount importance in planning surgery. Peroperative ductography proved the most useful in this regard.
Choledochal cysts in children and adults may behave differently. To identify these differences the records of 49 patients (22 children and 27 adults) who underwent surgery for choledochal cysts over a period of 7 years were analysed retrospectively. In two adult patients who had undergone a previous cholecystectomy an acquired malformation could not be excluded. Cholangitis was more common in adults. Choledochal cysts in children were predominantly Type I cystic lesions, whereas Type IV cysts were more common in adult patients. Anomalies of the pancreatic duct and associated hepatobiliary problems were seen exclusively in adults and the latter can make excision of the cyst more difficult and complicated. To prevent the development of complications choledochal cysts should be excised as soon as they are detected.
Cystic hydatid disease caused by Echinococcus granulosus most commonly involves the liver. Recent years have seen many changes in modalities of diagnosis and treatment of cystic disease in the liver. Currently used methods of immunodiagnosis, newer radiological modes of imaging, emerging non-surgical techniques of management and the impact of minimal access surgery in this disease are highlighted in the present review.
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The effect of H2 receptor antagonists on immediate cutaneous response to allergens remain controversial. In the present study, the effect of 7-day administration of omeprazole, cimetidine, famotidine and ranitidine on histamine induced wheal and flare reaction was evaluated. A single blind randomized parallel group study with within patient comparison of responses was planned in non-ulcer dyspepsia patients eligible to receive H2 antagonists or omeprazole. None of the drugs produced any changes in the area of the wheal in comparison to respective baseline values. The area of flare was decreased by all the drugs and the percentage decrease in this parameter caused by omeprazole, cimetidine, famotidine and ranitidine was 2.4, 12.3, 20.2 and 13.2, respectively. Only famotidine caused a significant decrease in flare area (p < 0.05).
Of 340 patients undergoing elective cholecystectomy for gallstone disease, 41 (12%) required an abdominal drain and 22 (65%) required a nasogastric tube postoperatively to control vomiting. Eighty six percent patients were discharged on the third post-operative day; 53% were satisfied with the early discharge. In our opinion, routine use of nasogastric tube and abdominal drain is not necessary and patients can be safely discharged on the third postoperative day after an uncomplicated cholecystectomy.
Forty infants with proven pyogenic meningitis were evaluated by real time cranial sonography. A spectrum of sonographic abnormalities was observed which included echogenic sulci, focal or diffuse increase in parenchymal echoes, ventriculitis, ventriculomegaly with or without aqueductal block, subdural collection, parenchymal infarcts, abscess and subdural empyema. There were two infants with normal sonogram while encephalomalacia was seen in another two patients. An excellent correlation was observed between clinical profile, cerebrospinal fluid biochemistry and sonographic findings.