G6PD deficiency in malaria endemic areas of Nepal.

BACKGROUND: Glucose-6-phosphate dehydrogenase (G6PD) deficiency is currently a threat to malaria elimination due to risk of primaquine-induced haemolysis in G6PD deficient individuals. The World Health Organization (WHO) recommends G6PD screening before providing primaquine as a radical treatment against vivax malaria. However, evidence regarding the prevalence and causing mutations of G6PD deficiency in Nepal is scarce. METHODS: A cross-sectional, population-based, prevalence study was carried out from May to October 2016 in 12 malaria-endemic districts of Nepal. The screening survey included 4067 participants whose G6PD status was determined by G6PD Care Start™ rapid diagnostic test and genotyping. RESULTS: The prevalence of G6PD deficiency at the national level was 3.5% (4.1% among males and 2.1% among females). When analysed according to ethnic groups, G6PD deficiency was highest among the Janajati (6.2% overall, 17.6% in Mahatto, 7.7% in Chaudhary and 7.5% in Tharu) and low among Brahman and Chhetri (1.3%). District-wise, prevalence was highest in Banke (7.6%) and Chitwan (6.6%). Coimbra mutation (592 C>T) was found among 75.5% of the G6PD-deficient samples analysed and Mahidol (487 G>A) and Mediterranean (563 C>T) mutations were found in equal proportions in the remaining 24.5%. There was no specific geographic or ethnic distribution for the three mutations. CONCLUSIONS: This study has identified populations with moderate to high prevalence of G6PD deficiency which provides strong evidence supporting the WHO recommendations to screen G6PD deficiency at health facility level before the use of primaquine-based radical curative regimen for Plasmodium vivax.

Chylolymphatic mesenteric cyst: A rare differential diagnosis of cystic mass in abdomen: A case report.

INTRODUCTION: Mesenteric cysts are the rare benign intraperitoneal tumor, which are common in the mesentery of the terminal ileum. Though mesenteric cysts are frequently seen, chylolymphatic mesenteric cysts in children are rare entities. CASE PRESENTATION: Our case is a case of a 3-year-old female child presenting to our center with a complain of abdominal pain. Ultrasonography (USG) of the abdomen revealed a cystic lesion in the right upper abdomen, and computed tomography (CT) scan showed a large homogenous fluid density lesion in the right upper abdomen, giving a provisional diagnosis of mesenteric cyst. She was managed surgically: the cyst was excised, the involved segment of bowel was resected and the remaining was anastomosed. On histopathology, the final diagnosis of a chylolymphatic mesenteric cyst was made. DISCUSSION: Clinical presentations may vary from asymptomatic abdominal lump to features of acute abdomen. Imaging modalities like ultrasonography and computed tomography scans are the mainstay of investigations. Surgical management with excision of cyst, and resection of the involved bowel segment is the treatment of choice, as done in our patient. The final diagnosis is made after the histopathologic examination of the excised specimen. CONCLUSION: Chylolymphatic mesenteric cysts are rare, and have varied clinical presentations. Although rare, chylolymphatic mesenteric cysts should be considered a differential diagnosis in patients presenting with cystic masses in the abdomen.

Prune belly syndrome: A rare case report.

Key Clinical Message: In babies presenting with an omphalocele, other components of the prune belly syndrome should be scrutinized for early diagnosis and timely intervention. Abstract: A male baby on his 13th day of life presented with an omphalocele. On evaluation, he had congenital absence of left kidney and bilateral cryptorchidism. Therefore, he was diagnosed with prune belly syndrome. He responded well to abdminoplasty, and wait and watch policy was applied for his cryptorchidism.

Giant isolated splenic hydatid cyst in a pediatric patient: A rare case report.

INTRODUCTION: Hydatidosis, caused by Echinococcus granulosus, is endemic in regions where cattle rearing is prevalent. While liver and lung involvement are common, isolated splenic hydatid cysts are rare, particularly among adolescents. We present a rare case of a 14-year-old female with an isolated giant splenic hydatid cyst. CASE PRESENTATION: A 14-year-old female presented with left upper quadrant pain. Imaging revealed a large splenic cyst without evidence of liver or lung involvement. A total splenectomy was performed, and a histological examination confirmed the diagnosis of a hydatid cyst. The patient underwent postoperative albendazole therapy and remained asymptomatic during follow-up. CLINICAL DISCUSSION: Isolated splenic hydatid cysts are rare in the pediatric population. Imaging techniques such as ultrasound and CT play a crucial role in diagnosis. Surgical resection and Puncture-aspiration-injection-reaspiration remain the choice of treatment, supplemented by anti-parasitic therapy. Postoperative follow-up is essential to monitor for recurrence. CONCLUSION: Isolated splenic hydatid cysts are exceptionally rare in pediatric patients. Prompt diagnosis, surgical intervention, and postoperative surveillance are crucial for successful management and prevention of recurrence.

Isolated pancreatic injury following blunt trauma in a seven-year-old girl: A case report.

INTRODUCTION AND IMPORTANCE: Isolated pancreatic injury following blunt abdominal trauma is rare, and the absence of definite clinical signs and symptoms may delay diagnosis and management. CASE PRESENTATION: We present the case of a seven-year-old girl with a history of progressive, periumbilical abdominal pain and multiple episodes of non-bilious, non-blood mixed vomiting following a road traffic accident. Computed tomography (CT) imaging revealed an isolated grade three pancreatic injury managed conservatively. CLINICAL DISCUSSION: The patient usually presents with epigastric tenderness with or without a rise in pancreatic enzyme levels. CT grading of injury correlates with and guides the management approach, and CT abdomen with contrast is the preferred investigation for diagnosis. Management depends on the grade of injury, the hemodynamic status of the children, and the co-existence of other injuries. CONCLUSION: Isolated pancreatic injury, although rare, can go undiagnosed due to a lack of suspicion from the treating surgeon and may have dire consequences. Conservative management can be a suitable strategy for children with stable hemodynamic status.

Diffuse large B-cell lymphoma in a patient treated with azathioprine for ulcerative colitis: a case report.

Azathioprine (AZA) used as an immunomodulator agent in the management of inflammatory bowel disease (IBD) increases the risk of the development of lymphoma. Case presentation: We present a case of a 45-year-old female receiving AZA for severe ulcerative colitis for 4 years. She presented with the chief complaints of bloody stool and abdominal pain for 1 month. Through a series of investigations including colonoscopy, contrast-enhanced computed tomography scan of the abdomen and pelvis, and biopsy with immunohistochemistry; she was diagnosed to have diffuse large B-cell lymphoma of the rectum. She is currently on a chemotherapeutic regimen and is planned for surgical resection after the completion of neoadjuvant therapy. Clinical discussion: AZA is classified as a carcinogen by the International Agency for Research on Cancer. Prolonged exposure to higher doses of AZA increases the risk of developing lymphoma in IBD. Previous meta-analysis and research indicate that the risk of development of lymphoma after the use of AZA in IBD increases by about four- to six-fold, especially in older age groups. Conclusions: AZA may increase the susceptibility to developing lymphoma in IBD, but the benefit far outweighs the risk. Precautions must be taken in prescribing AZA in older individuals which mandates periodic screening.

Comparison of Acute Physiology and Chronic Health Evaluation II, Bedside Index for Severity in Acute Pancreatitis and Modified Computed Tomography Severity Index Scores in Predicting the Outcome in Acute Pancreatitis in a Tertiary Care Centre in Nepal.

BACKGROUND: It is important to identify the severity of acute pancreatitis in the early course of the disease. METHODS: This prospective observational study included 83 patients with acute pancreatitis. The Acute Physiology and Chronic Health Evaluation II and the Bedside Index for Severity in Acute Pancreatitis scores were assessed within 24 hours of admission, and the modified computed tomography severity index score was calculated in those patients who underwent contrast enhanced computed tomography.  The sensitivity, specificity, positive predictive value, and negative predictive value of scoring systems were calculated. The area under the curve was calculated for assessing the prognostic value of scoring systems. RESULTS: The modified computed tomography severity index was the most accurate score in predicting severity and local complications with an area under the curve of 0.92 and 0.91, respectively. The Bedside Index for Severity in Acute Pancreatitis score was the most accurate in predicting organ failure and the need for intensive care unit admission with an area under the curve of 0.70 and 0.78 respectively. CONCLUSIONS: The results of this study demonstrate that modified computed tomography severity index and Bedside Index for Severity in Acute Pancreatitis scores had overall better predictive value than the Acute Physiology and Chronic Health Evaluation II score in predicting severity, organ failure, local complication, and need for intensive care unit admission.

Persistent Vitello-Intestinal Duct Masquerading as Acute Appendicitis: A Case Report.

The vitello-intestinal duct normally regresses with the development. But, in certain cases, it could persist and present as Meckel's diverticulum. Here we report a case of an eight-year-old boy presenting with peri-umbilical abdominal pain, vomiting and loose stool. He was initially diagnosed and managed as acute appendicitis but did not improve, rather developed features of intestinal obstruction. Exploratory laparotomy was done which revealed persistent vitello-intestinal duct and was managed surgically. This case report highlights that in any case of suspected acute appendicitis, the complications of persistent vitello-intestinal duct should be considered as one of the differentials. Keywords: appendicitis; case reports; intestinal obstruction; laparotomy; omphalomesenteric duct.

Cytomegalovirus hemorrhagic colitis in an immunocompetent patient with COVID-19 infection: A case report.

In coronavirus disease-19, we should suspect the opportunistic coinfections even in immunocompetent individuals. In the presence of recurrent gastrointestinal problems, colonoscopy should be done with biopsy and histopathology to diagnose the opportunistic infection, such as cytomegalovirus colitis, in patient with coronavirus disease-19. Here, we report a case of immunocompetent male with coronavirus disease-19 presenting with per rectal bleeding diagnosed as cytomegalovirus colitis.

Liver Cirrhosis among Young Adults Admitted to the Department of Gastroenterology in a Tertiary Care Centre: A Descriptive Cross-sectional Study.

Introduction: Cirrhosis in young adults is an important health problem worldwide and is a common disease. Patients usually present late in a decompensated state with varied complications. However, national data on the exact burden of the disease is lacking. The aim of this study was to find out the prevalence of liver cirrhosis among young adults admitted to the Department of Gastroenterology in a tertiary care centre. Methods: A descriptive cross-sectional study was done among patients admitted to the Department of Gastroenterology in a tertiary care centre between 25 November 2021 to 30 November 2022 after receiving ethical approval from the Institutional Review Committee [Reference number: 227(6-11)E2-078/079]. Convenience sampling was done. Point estimate and 95% Confidence Interval were calculated. Results: Among 989 patients, liver cirrhosis in young adults was seen in 200 (20.22%) (18.12-22.32, 95% Confidence Interval). Chronic alcohol use was the primary cause of cirrhosis seen in 164 (82%) cases. The most typical presenting symptom was abdominal distension seen in 187 (93.50%) patients. The most frequent complication was ascites seen in 184 (92%) patients. The most frequent endoscopic finding was gastro-oesophagal varices seen in 180 (90%) patients. There were 145 (72.50%) men and 55 (27.50%) women. Conclusions: The prevalence of liver cirrhosis in young adults was found to be lower than the other studies done in similar settings. Keywords: ascites; liver cirrhosis; prevalence.

Delayed presentation of isolated ductal rupture of pancreatic head from blunt abdominal trauma managed conservatively: A case report.

Introduction: and Importance: Blunt abdominal injury causing significant and isolated major pancreatic injury is rare in adolescents and young adults, with a controversial approach to its management. Case presentation: We present our experience of diagnosis and management of the ductal injury of the pancreatic head (Grade III) in the setting of blunt abdominal trauma in a 20-year-old male diagnosed by a series of various tests including magnetic resonance cholangiopancreatography (MRCP) and managed by pigtail drainage and octreotide alone; contrary to the previous recommendations of management of high-grade pancreatic trauma through surgical approach or endoscopic retrograde cholangiopancreatography (ERCP) and stenting. Clinical discussion: Isolated ductal rupture of the pancreatic head can have delayed presentation within a window of time and can be diagnosed by a series of tests including hematological, biochemical, and radiological investigations. Conservative treatment is generally recommended for Grade I and II whereas a surgical approach is preferred for higher grade pancreatic injury. Conclusions: Pancreatic ductal injury must be kept in mind when present with vague symptoms in the setting of blunt abdominal trauma. Magnetic resonance cholangiopancreatography (MRCP) is the investigation of choice for the diagnosis of pancreatic ductal injury. Even higher-grade pancreatic injury (grade III) can be managed with a conservative approach with pigtail drainage and an appropriate dosage of octreotide.

Evaluation of portal venous system in post splenectomised beta-thalassemic children: A prospective study in a tertiary care hospital.

Background: Splenectomy is a palliative management technique in children with ß-thalassemia. Portal thrombosis is the most dreaded complication after splenectomy that requires fast diagnosis, effective therapy, and good follow-up to prevent protal hypertension. Thus, there is the importance of constant evaluation of portal venous system through Color Doppler Ultrasound. This cohort study aimed to observe the changes in the portal venous system in post-splenectomised ß-thalassemic children. Material and methods: This is a prospective observational cohort study carried out on all the pediatric patients who have undergone splenectomy in Bangabandhu Sheikh Mujib Medical University, Dhaka Bangladesh from 2017 to 2019 for ß-thalassemia. The color doppler of the portal venous system was done within the 7th to 10th post-operative day and after 3 months. Outcomes like mean the caliber of the portal vein, mean velocity within the portal vein, and color Doppler findings like Portal Vein Thrombosis (PVT) and Pathological change in Mean Volume (PMV) were calculated and compared in two headings: pre-operative period and postoperative period (7-10 POD and 3 months) with the help of paired t-test. Results: Twenty-Eight ß-thalassemia patients with a mean age of 10.43 ± 3.91 years planned to undergo splenectomy were included in our study. The pre-operative mean caliber and mean velocity of the portal vein were not statistically significant when compared after the postoperative period (7-10 POD and 3 months). But, continuous changes in portal vein were seen that could lead to normalization or pathological changes. Conclusion: There are physiological and pathological changes in portal vein following splenectomy that could lead to varied complications like portal vein thrombosis and portal hypertension. Color Doppler Ultrasound findings along with close follow-up help in minimizing the pathological changes and complications.

Risk factors for recurrent intussusception after successful reduction in pediatric patients in a tertiary care hospital of Nepal: A prospective study.

Background: Intussusception is defined as the invagination of one segment of intestine into another segment of intestine. It may recur because of persistence or return of some factor responsible for the primary intussusception. Various risk factors have been reported but still not well elucidated. Materials and methods: This is the prospective observational study. In this study, 78 patients, age <16 years with diagnosis of intussusception between June 2019 and April 2020 who had successful reduction with either hydrostatic reduction and/or operative reduction in Teaching Hospital were enrolled in the study. This is study of early recurrence as patients were followed up to a period of 1 month for recurrence of intussusception. The recurrent cases were thus identified and various variables were compared between recurrent and non-recurrent cases by univariable and multivariable analysis. Results: Among 78 patients, 13 patients (16.7%) had recurrent intussusception. In the univariable analysis model, the significant risk factors for recurrence of intussusception analyzed were duration of symptoms of 48 h or more, fever, blood in stool and palpable mass. While after multivariable analysis, we found that the significant risk factors for recurrence of intussusception were duration of symptoms ≥48 h (OR = 5.32, p-value = 0.047), Fever (OR = 17.32, p-value = 0.001), palpable mass (OR = 24.12, p-value = 0.017). Conclusion: Attention and awareness among pediatricians about these sonographic and clinical risk factors especially symptoms for recurrence are needed to minimize pre-hospital delay and identify patients in risk of recurrence. This ultimately helps to improve care for pediatric patients with recurrent intussusception.

Large intestine as content of congenital inguinal hernia: A case report of intestinal obstruction.

Introduction and importance: Hernias containing appendix, caecum and transverse colon are uncommon in contrast with usual inguinal hernias containing small intestine. The patient usually presents with inguinoscrotal swelling. Case presentation: We present a case of a 2 months old male child presented with inguinoscrotal swelling, vomiting with abdominal distention. On Ultrasonography (USG) of the scrotum, protrusion of the abdominal cavity contents through the right inguinal canal into the scrotum of approximately 3.4 cm × 0.7 cm was found which indicates right inguinal hernia. On the opening of the hernia sac during surgical management, the appendix, caecum and transverse colon were lying inside the hernia sac. Open Herniotomy was performed and the abdomen was closed in layers. Postoperative period of the patient was uneventful. Discussion: Congenital inguinal hernia in the child occurs mostly due to persistent processus vaginalis. History and clinical examination reveals the appearance of lump in the inguinal region or scrotum. Preoperative Ultrasonography can be used to supplement the physical examination and increase the accuracy of its diagnosis. Although the laparoscopic approach is increasingly used nowadays, open hernia repair is preferred in young children. Conclusion: Appendix, caecum and transverse colon are unusual contents of an inguinal hernia. Open herniotomy combined with relieving of the intestinal obstruction is the treatment of choice in young children.

Clinical profile and management of perforation peritonitis in Bharatpur hospital, Nepal: A prospective study.

Introduction: The most common surgical emergency in general surgery is perforation peritonitis. It is a serious condition with a mortality rate of up to 20%, and it is the third most common cause of surgical abdomen after appendicitis and intestinal obstruction. The aim of this study to discuss clinical profile and management of perforation peritonitis in a hospital in central Nepal. Methods: This prospective study was done for one year at Bharatpur Hospital, Chitwan Nepal. In our study, only patient above 15 years were included and those who were not fit for anesthesia and surgery were excluded. Most of the patient were diagnosed clinically supported by lab investigations and imaging like X-ray and ultrasonography of abdomen. The variables analyzed were the risk factors of the patient like smoking, alcohol, liver disease and previous abdominal surgeries. Results: The majority of the patients were in the age group 50-59 years in male and 40-49 years in female. Among sixty cases, 31 were female and 29 were male with Female: Male ratio of 1.06:1. The most common cause of perforation found was peptic ulcer compromising 88.3% (53 cases) followed by appendicular perforation accounting 8.3% (5 cases). Similarly, Tubercular perforation was found in 3.3%. Smoking was most common risk factor accounting 88.3%, followed by alcohol consumption (48.33%) while, 15% of patients had positive history of NSAIDs consumption. On imaging, 38.33% patient had air fluid level on X-ray and 78.33% had gas under diaphragm. On blood investigation, leukocytosis was found in 53.33% of patients, hyponatremia in 10% of patients and hypokalemia in 18.33% of patients. While on urine examination, albumin was found in 5% of patients. The repair of perforation along with omentopexy was done in 73.3% of patients while only repair was done in 15% of patients. Only 8.3% opted for appendectomy while a very few patients (3.3%) went for resection with anastomosis. The Postoperative complications found were wound infection (43.3%), paralytic ileus (18.33%), sepsis (15%), followed by electrolyte imbalance (11.6%), postoperative bowel obstruction (6.6%) and burst abdomen (1.6%). While, there were only 3 cases of mortality. Conclusions: Perforation peritonitis is a frequently encountered surgical emergency. Various factors like age, sex, duration, site of perforation, extent of peritonitis and delay in surgical intervention are associated with morbidity and mortality. A successful management depends upon early surgical intervention, source control and exclusive intraoperative peritoneal lavage.

Role of Hyperbilirubinaemia as a Predictor of Complicated Appendicitis in Paediatric Population.

BACKGROUND: Acute appendicitis is a common surgical emergency amongst the paediatric population. Available diagnostic tools are focussed to make a diagnosis of acute appendicitis. A definitive predictive factor for the diagnosis of complicated appendicitis is lacking. Thus, this aims to analyse hyperbilirubinaemia as a predictor of complicated appendicitis amongst the paediatric population. MATERIALS AND METHODS: A prospective observational study was conducted in a tertiary hospital from November 2018 to October 2019. All children undergoing emergency appendectomy were included in the study. Preoperatively, patients were evaluated clinically, and routine investigations including total and direct serum bilirubin were sent. All patients were grouped as 'simple appendicitis' or 'complicated appendicitis' based on intra-operative and histological findings. Bilirubin level was compared between these groups and analysed. RESULTS: A total of 52 children fulfilling the inclusion criteria were included. The mean age was 13.2 ± 4.2 years, and the male: female ratio was 2.1:1. Thirty-four (65.4%) had simple appendicitis and 18 (34.6%) had complicated appendicitis. Total bilirubin was 23.83 ± 5.94 mmol/L in the complicated appendicitis group and 13.15 ± 3.29 mmol/L in the simple appendicitis group. Direct bilirubin was 5.28 ± 2.22 mmol/L in complicated appendicitis and 2.62 ± 0.83 mmol/L in simple one. Both total and direct bilirubin were significantly high in the complicated group (P < 0.001) compared to the simple appendicitis group. On the Receiver operating curve (ROC), the best cutoff value for total and direct bilirubin was 21 and 5.5 mmol/L, respectively. The sensitivity and specificity of total and direct bilirubin were 72.2%, 100%, and 61.1%, and 85.3%, respectively. CONCLUSION: It is concluded that hyperbilirubinaemia is a good predictor for paediatric complicated appendicitis.

Sleeve gastrectomy for multiple gastric perforations in a preterm: A case report.

Neonatal gastric perforation (NGP) is a rare life-threatening condition among preterm infants. NGP can occur secondary to necrotizing enterocolitis, distal obstruction, or as a result of gastric tube insertion. Sleeve gastrectomy can be a possible therapeutic option for multiple neonatal gastric perforations.

Torsed gangrenous Meckel's diverticulum causing gangrenous ileal segment: A rare case report of small bowel obstruction in children.

INTRODUCTION: Meckel's diverticulum (MD) is the most common congenital anomaly of the gastrointestinal system. It is caused by an incomplete obliteration of the vitelline duct. Rarely, it can present with complications like torsion and gangrene formation. CASE PRESENTATION: A 13-year previously healthy girl presented with sudden onset periumbilical pain and bilious vomiting who was subsequently diagnosed with Meckel's diverticulum. Intraoperatively, torsed gangrenous diverticulum forming band adhesion was found. Resection of Meckel's diverticulum along with gangrenous ileal segment followed by ileoileal anastomosis was done. DISCUSSION: Axial torsion of Meckel's diverticulum with gangrene formation is a rare occurrence. Mesodiverticular band adhesion along with herniation of small bowel segments under it endangers viability of herniating segments. Preoperative diagnosis of complicated MD is difficult as it mimics other common acute abdominal conditions. CT scan and enteroclysis are imaging modalities of choice. Surgical resection of MD along with resection and anastomosis of gangrenous bowel segment results in complete cure. CONCLUSION: Meckel's diverticulum with complications should be kept in the differential of acute abdominal conditions presenting with atypical symptoms. Surgical resection ensures complete cure.

Hirschsprung disease with Edward syndrome: A rare association: A case report.

INTRODUCTION AND IMPORTANCE: Edward's syndrome (ES) occurs as a result of trisomy of chromosome 18 and is associated with multisystem congenital anomalies. The association of ES with various gastrointestinal malformations but Hirschsprung disease (HD) is well documented. CASE PRESENTATION: A female infant on her 5th day of life presented with episodes of bilious vomiting along with abdominal distension and no passage of stool. The child had a small head and prominent occiput, low set abnormal ears, small jaw, upturned nose, widely spaced eyes, small neck with widely spaced nipples, clenched hands with overlapping fingers, flexed big toe, and prominent heels. CLINICAL DISCUSSION: Edward syndrome is associated with multisystem congenital abnormalities of which gastrointestinal abnormalities make up the most part. The condition can be identified by fetal ultrasound screening. Surgical correction of associated congenital anomalies at different times along with lifelong supportive management is important. CONCLUSIONS: Edward syndrome can present as Hirschsprung disease as a part of associated gastrointestinal Malformation. Often, early identification and termination of the pregnancy in antenatal life can reduce the suffering. Surgical correction of associated anomalies along with supportive care forms the cornerstone of management. However, the prognosis remains poor.

Perforation of gastroesophageal junction, stomach, and diaphragm following blunt abdominal trauma: A near miss: A case report.

INTRODUCTION: Blunt abdominal trauma causing Gastro-esophageal junction (GEJ), diaphragm, and gastric perforation in children is a very rare occurrence. However, the injury is serious and life-threatening with significant morbidity and mortality. PRESENTATION OF CASE: We report an unusual case of a 14-year-old boy with an accidental fall from the tree with blunt abdomen trauma with a perforating injury to GEJ, stomach, and diaphragm. DISCUSSION: Multiple vital organs in the abdominal cavity are vulnerable to damage in blunt abdominal trauma. The rarity of perforation, diagnostic delay, and early septic occurrence sums up to higher patient morbidity and mortality. A high degree of suspicion and urgent laparotomy and surgical repair forms the cornerstone in management. CONCLUSION: Early suspicion along with effective resuscitation and early laparotomy and surgical repair is crucial for survival and optimal outcome of the patient.