A unique method for management of benign colonic masses: case report

Even though lipomas are most common non-epithelial tumors of the large intestine, they mostly present with non-specific symptoms. Intussusception is the most common morbidity related to such lesions and may present as intestinal obstruction. We present here a case of a young female who presented to gastroenterology department as a case of pain abdomen and nausea and a provisional diagnosis of subacute intestinal obstruction was kept. Contrast enhanced CT confirmed a diagnosis of intussusception due to an ascending colon mass? likely lipoma. The colonoscopy was done and biopsy was taken which was non-specific for malignancy. Patient, after taking due consent, was taken for surgery and laparoscopic assisted submucosal excision of lipoma was done and we will discuss the same. Endoscopic excision of lipomas has been reported but when failed, mostly segmental resection of the colon has been reported. To the best of our knowledge, this is the second reported case of laparoscopic assisted colotomy with submucosal excision of an intussuscepting colonic lipoma and first one in ascending colon.

Ciprofloxacin and Metronidazole Allergy- A Case Report

Fluoroquinolones are well-tolerated antibiotics widely used for treating infections. According to the literature, ciprofloxacin is mostly involved in Drug-induced hypersensitivity reactions. The various reactions that are reported in various case reports due to ciprofloxacin include Steven Johnson syndrome, eczema, erythroderma, maculopapular rashes. Metronidazole is a 5-nitroimidazole compound introduced in 1959 to treat Trichomonas vaginalis infections. Ciprofloxacin and Metronidazole hypersensitivity is not very frequent it is usually well tolerated but allergic reactions to these drugs occur due to their increased use either alone or in combination. An 83-year-old female was admitted to the private ward of surgery at Shri Mahant Indiresh hospital with chief complaints of abdominal pain and chronic constipation as the patient was not passing stools for 10 days. The patient was diagnosed with Subacute intestinal obstruction (SAIO) based on various laboratory findings and the symptomatic treatment was given treatment. Hypersensitivity reactions can be of two types immediate that occurs within few hours of drug administration and delayed that occurs within 24-48 hours of drug administration. Here in this case the person developed vomiting immediately after few hours of Ciprofloxacin administration so it is an immediate IgE mediated anaphylactic reaction. Metronidazoleis causing Type 4 Delayed hypersensitivity reaction in this patient as rashes and itching developed the next day after administration of metronidazole drug. Healthcare professionals should maintain the record of a medication history of the patient to identify any drug allergy so that it can be avoided in the future and in case of any ADR it should be reported. The patient should be advised to go for a sensitivity test to check which drug he/ she is allergic to and should avoid taking that medication. The patient should tell his/ her history of drug allergy to the doctor so that doctor doesn’t prescribe that medication. Keywords: CBC-Complete Blood Count, RFT-Renal Function tests, LFT-Liver function tests, Hb-Hemoglobin, SGOT-Serum Glutamic oxaloacetic transaminases, ALP-Alkaline phosphatase, MCH-mean corpuscular Hemoglobin, MCHC-Mean corpuscular hemoglobin concentration, RBC-Red Blood Cells, SAIO-Subacute intestinal obstruction, USG- Ultrasound.

A Descriptive study on Conservative Management of Subacute Intestinal Obstruction and Its Outcome in Tirupati

BACKGROUND Intestinal obstruction can be defined as the partial or complete blockage of either the small intestine or large intestine or both, causing failure of intestinal contents to pass beyond the point of obstruction. Subacute intestinal obstruction implies incomplete obstruction. It is characterized by continuous passage of flatus and /or feces beyond 6 -12 hours of the onset of symptoms. We wanted to study the conservative management of subacute intestinal obstruction and its outcome. METHODS Data was collected from patients presenting to outpatient Department of General Surgery, SVRRGGH, Tirupati and emergency with the features of subacute intestinal obstruction during the period of March 2019 to April 2020 were included in the study. RESULTS The incidence is high in patients of age group 41-50 years with Male: Female ratio is 2.1:1. The most common presenting symptom is pain abdomen (92 %), followed by vomiting (84 %). In our study, exaggerated bowel sounds (60 %) are the most common physical finding. The most common cause of obstruction is Postoperative adhesions (36 %), followed by obstructed hernias (22 %). Out of 50 cases, 72 % of cases were managed successfully by conservative management. In the patients who were managed conservatively, most of them are due to postoperative adhesions. In the patients who underwent emergency surgical intervention, 50 % of cases operated on the 2nd day of admission. Most commonly done Surgery include Adhesiolysis (28.6 %), Herniorrhaphy (28.6 %) and Resection and anastomosis (21.5 %). CONCLUSIONS Our study showed that conservative management is successful in about 72 % of patients with subacute intestinal obstruction. Not all the patients attending the emergency ward with features of intestinal obstruction need emergency surgical intervention. Conservative management can be tried in selective cases in patients with SAIO, thereby reducing the rate of negative laparotomies and morbidity and mortality. KEYWORDS Sub-Acute, Intestinal, Obstruction Conservative, Outcome

Concurrent intestinal malrotation and Meckel's diverticulum presenting as acute intestinal obstruction in an adult

Intestinal malrotation is the partial or complete failure of rotation of midgut around the superior mesenteric artery, while Meckel’s diverticulum is the remnant of vitellointestinal duct and concurrence of these congenital abnormalities in an adult is considered a rarity. Till date only 3 cases of concurrent intestinal malrotation and Meckel's diverticulum have been reported. We report a 18 years male who presented with a 3 day history of abdominal pain, bilious vomiting, obstipation and chronic abdominal pain on and off since 3 years of age. During the last episode which occurred 1 year back, he was diagnosed with intestinal malrotation with subacute intestinal obstruction and was treated conservatively. Examination revealed the presence of signs of peritonitis. After resuscitation, CECT abdomen was taken which showed dilated small bowel loops in the subhepatic region associated with malrotation. Emergency laparotomy revealed a Ladd's band below which the gangrenous small bowel loops 150 cm from the duodenojejunal (flexure until 5 cm proximal to the ileocecal junction) were found herniating into the subhepatic region with a Meckel’s diverticulum and a right sided DJ flexure. We proceeded with the band release and resection of gangrenous bowel followed by proximal jejunostomy with distal ileostomy. HPE was consistent with Meckel’s diverticulitis without any ectopic gastric or pancreatic mucosa. Ostomy reversal was done after 8 weeks. Patient had an uneventful postoperative recovery during both the admissions and he is on regular follow-up now.

Curious Case of Peritoneal Loose Body

Peritoneal loose bodies (PLB) also known as “peritoneal mice”, are rare lesions often found incidentally during laparoscopies or laparotomies. They are often small in size although PLBs measuring in size more than 5 cm have also been reported. Most small PLBs remain asymptomatic and do not require treatment, although large PLBs have also been known to cause symptoms like urinary obstruction, intestinal obstruction. We present one such case of a middle- aged man having a PLB causing subacute intestinal obstruction.

Real-World Experience in Toxicity with Bevacizumab in Indian Cancer Patients

Background Bevacizumab, a humanized monoclonal antibody, known to block the binding of all known vascular endothelial growth factor-A isomers to their receptors, is used in solid cancers, especially in advanced settings where its role is proven to be stronger than localized stages. Furthermore, various studies have suggested that adding bevacizumab to first-line standard therapy in advanced solid cancers, such as colorectal cancer, lung cancer, ovarian cancer, renal cancer, and breast cancer, significantly prolongs progression-free survival, overall survival, and response rates. However, this ability is limited and variable in cancer subtype. The toxicity profile of bevacizumab is outspread, ranging from mild gastrointestinal side effects, proteinuria to life-threatening hemorrhagic tendency, ischemic thromboembolism, and intestinal perforation. However, it has never been studied in Indian subset of patients till date. Materials and Methods We performed an institutional retrospective study of 41 patients with a pathologically proven ovarian, colorectal, lung, mesothelioma, melanoma, round cell tumors, and GBMs who received bevacizumab (2.5 mg/kg/week [5 mg/kg every 2 weeks or 7.5 mg/kg every 3 weeks]) with or without chemotherapy, between January 2016 and January 2019 at our center in North India. Results Forty-one patients, including 12 (29) advanced ovarian cancer, 12 (29) colon cancer, 10 (24) rectal cancer, 1 (2) appendicular cancer, 1 (2) mesothelioma, 1 (2) melanoma, 1 (2) desmoplastic round cell tumor, and 3 (7) GBM, were treated with bevacizumab. The incidence of arterial thrombus and hemorrhage was 2 and 10%, respectively, whereas venous thrombus and fistula were not seen and not related to age. No fatal adverse event was recorded. The global incidence of severe (grade 3/4) arterial hypertension (HTN) was 49%. It was safely managed in all cases, and no grade 4 (life-threatening complication) occurred. The incidence of severe HTN was significantly higher in elderly patients than in younger ones (72 vs. 40%), proteinuria was found to be more frequent in the younger age group as compared with older age group (7 vs. 3%). Also to note, the incidence of congestive heart failure and subacute intestinal obstruction was found in 5% of patients, wherein all four patients belonged to the older subgroup. Furthermore, Grade 3 hypersensitivity reaction was found in one patient in the younger subgroup which warranted immediate termination of bevacizumab.

Results of the Surgical Treatment in Children with Hirschprung Disease: A 12-Year Experience

Objective: In the treatment of Hirschsprung’s disease, many surgical techniques have been developed and modified including laparotomy, resection of the affected colon segment, and pull-through of the functional bowel segment to the anus. Conventional surgical methods have many early and late postoperative complications, albeit at a reduced rate today. In this study, it was aimed to compare the treatment results of children with Hirschsprung Disease who were operated with single or two-stage techniques in our department. Method: Hospital records of the patients operated for Hirschsprung disease were retrospectively evaluated. Demografic characteristics, findings of physical and rectal examinations, X-rays findings, rectal biopsy results, surgical treatment methods and outcomes were analyzed. Results: Fifty-two children including 41-male (78.8%) and 11-female (21.2%) patients with age ranging from 1-day to 5-year and mean age of 6.8-day in neonates and 6.3-month in others were enrolled in the study. All patients presented with acute or subacute intestinal obstruction. Levels were observed on supine abdominal radiographs in all; transition zone and retention of opaque material were observed on opaque enema or retention radiographs.In patients whose rectal biopsies revealed aganglionic megacolon two staged procedures were performed including initial colostomy followed by definitive procedure of Duhamel with stapler in 30, and Soave in 12, and Swenson in 1 patient. Nine patients were operated with one-stage endorectal pull-through technique. The complication rate in 43 patients with Hirschsprung disease managed by two staged operative procedure was (78.8%), and it was 11.1% in 9 cases that underwent transanal endorectal pullthrough procedure. It was learned that effective anal dilatation was not performed in 22-patients who had postoperative enterocolitis attacks. Conclusion: In addition to the low complication rate, the morbidity rates in the transanal endorectal pull-through method, which achieved successful results with only one procedure, were very low compared to multiple-stage operations.