A Rare Presentation of Duodenal Diverticulum Causing Obstructive Jaundice: Lemmel's Syndrome.

Lemmel syndrome is an uncommon pancreaticobiliary consequence of duodenal diverticula. We herein present a case of an 80-year-old male who presented with upper abdominal discomfort. Based on lab values and relevant clinical history, a diagnosis of obstructive jaundice was made. A contrast-enhanced CT scan of the abdomen revealed gross dilatation of intra-hepatic and extra-hepatic bile duct, cystic duct, common bile duct, major and minor pancreatic duct. A contrast-filled outpouching was seen from the medial wall of the second part of the duodenum with duodenal diverticulum and papilla within it. The abrupt termination of the common bile duct and main pancreatic duct adjacent to the thickened wall of the diverticulum was the cause of the patient's pancreaticobiliary obstruction. In the absence of cholelithiasis or tumor, the duodenal diverticulum that manifests as obstructive jaundice is known as Lemmel syndrome. Prompt identification of Lemmel syndrome can avoid dangerous complications and unnecessary investigations. Gallstones, cholangitis, and bile duct stones are more common in patients with duodenal diverticula. Treatment depends on patient presentation and may involve conservative management, surgical procedures in the form of excision of the diverticulum, or even endoscopic sphincterotomy or stenting.

Assessment of Functions of the Autonomic Nervous System in the Elderly with Different Comorbid Factors.

Background Studies in healthy elderly patients have shown the prevalence of autonomic dysfunction (AD) in the range of 20 to 30%. However, there is paucity in data pertaining to AD in the elderly in the Indian context. Objective To assess the prevalence of AD in the elderly irrespective of their comorbidity status. Methods A total of 141 elderly patients with or without comorbidities/symptoms of AD were included. Demographic and clinical details of the patients were recorded. Autonomic function tests (AFTs) such as deep breathing test, Valsalva ratio, orthostatic heart rate (OHR), isometric handgrip test, and orthostatic blood pressure were performed based on Ewing's battery of tests. The sensitivity, specificity, positive predictive value, negative predictive value, and the accuracy of AFTs were evaluated. Results Most patients ( n = 85) were aged between 60 and 69 years, with a male predominance (58.87%). Hypertension and diabetes mellitus were the most common comorbidities. Postural hypotension was the most common symptom of AD. With advancing age, symptoms of AD manifested significantly more. Overall, 73.8% of patients had AD, of whom 45.4% had early AD. Number of AD symptoms, glycated hemoglobin (HbA1c) level, and comorbid factors (diabetes and hypertension) were significantly associated with the results of AFTs ( p < 0.05). AFTs were highly significant with respect to the results obtained ( p < 0.001). Deep breathing test, abnormal in majority of study patients, has a sensitivity of 93.3% and OHR has a specificity of 81.1% to determine AD. Conclusion The study concludes that age itself is an independent predictor of AD, which increases in severity if associated with comorbidities.

Effects of Different Concentrations of Fluoride in Oral Mucosal Cells in Albino Rats.

INTRODUCTION: Fluoride has been described to be physiologically essential for the normal development and growth of human beings. However, it is well known that excessive fluoride causes skeletal, nonskeletal and dental complications. Therefore, outlining the cytogenetic effects induced by fluorosis is necessary. OBJECTIVES: To evaluate the cytomorphology of exfoliated oral mucosal cells among various concentrations of fluoride. STUDY DESIGN: Study group comprised of 12 Albino Wistar rats, categorized into A,B and C groups (fed with 25 ppm,50 ppm and 100 ppm concentration of NaF), each group consisting of 4 rats, with 4 controls (fed with 1ppm concentration of NaF in distilled water). Each group was fed for a period of 42 days. MATERIALS AND METHODS: Cytological smears were taken from the buccal mucosa of each group after 42 days of fluoride administration. The samples were stained with the papanicolaou method and assessed for Cytomorphometrical changes in maximum diameter of nucleus, minimum diameter of nucleus, perimeter of the nucleus, maximum diameter of the cell, minimum diameter of the cell and perimeter of the cell by image analysis software and the results were statistically analysed using SPSS software. RESULTS: Mean values of maximum diameter, minimum diameter and perimeter of the nucleus increased in fluoride induced study groups when compared to controls and the results showed that p-value was statistically significant (p-value: 0.000, 0.001). Mean value of maximum diameter, minimum diameter and perimeter of the cell decreased in fluoride induced subjects when compared with controls which were statistically not significant (p-value: 0.791, 0.600 & 0.719). A continuous increase in the nuclear size and decrease in the cell size was identified in fluoride induced groups as compared to controls. CONCLUSION: The observations of our present study revealed that cellular changes occur with severity of fluorosis. These cellular morphological changes may possibly eventuate into dysplastic alterations, which can progress to malignant changes.

Anaesthetic management of pulmonary stenosis already treated with pulmonary balloon valvuloplasty.

The presence of congenital valvular heart disease can pose a challenge to anaesthetists in paediatric patients planning for incidental surgeries. Most of the available case reports from various journals describe the anaesthetic management in adults, whereas, pulmonary stenosis can present anytime during childhood and adolescence. The present case-report highlights anaesthetic management in a 9-year-old child, who was diagnosed with severe pulmonary stenosis that was already treated with pulmonary balloon valvuloplasty, yet had an eventful perioperative period due to residual valvular dysfunction.

Ultrasound guided fnac of abdominal-pelvic masses-the pathologists' perspective.

INTRODUCTION: Fine Needle Aspiration(FNA) which is used for making a cytologic diagnosis has become an indispensable component of the work-up of many abnormalities.The objectives of this study were to adopt USG guided fine needle aspiration in the diagnosis of abdomino-pelvic masses, to assess its efficacy and to study the cytological features of abdominopelvic masses. MATERIALS AND METHODS: Hundred patients with clinically or sonologically diagnosed abdomino-pelvic masses were taken up for the study. FNAC was performed under real time USG guidance. The aspirates were smeared onto a minimum of 2 slides and they were routinely stained with H&E, MGG and Papanicolaou stains. OBSERVATIONS: The diagnostic accuracy rates of USG guided FNAC for benign, malignant and non-neoplastic lesions were 100%,96% and 94.4% respectively.The overall accuracy rate was 96.3%. CONCLUSION: USG guided FNAC is a rapid , economical,non-invasive, highly accurate and a safe diagnostic procedure which can pre-empt a lengthy and expensive workup in various abdomino- pelviv masses.