Isotretinoin as a Possible Cause for Eosinophilic Esophagitis and Eosinophilic Gastroenteritis: A Case Report.

A 39-year-old female patient who took isotretinoin for severe acne for around six months presented with severe upper abdominal pain, as well as abdominal distention. Initially, she was diagnosed with acute cholecystitis due to the presence of gallstones on ultrasound. However, additional imaging showed mural thickening of the bowel, for which she underwent further work-up. Laboratory investigations showed raised inflammatory markers along with eosinophilia. Concurrently, bedside paracentesis showed raised levels of eosinophils. The patient underwent an endoscopic assessment, which revealed eosinophilic esophagitis and gastroenteritis likely to be induced by isotretinoin. Following the discontinuation of isotretinoin and the initiation of corticosteroid therapy, the patient's clinical condition improved significantly. The diagnosis of eosinophilic gastrointestinal disorders, though rare, must be kept in mind when patients on long-term isotretinoin treatment or with other risk factors present with symptoms such as dysphagia, abdominal pain, odynophagia, nausea, and vomiting.

Abdominal Tuberculosis Presenting With Small Bowel Obstruction: A Case Report.

Abdominal tuberculosis (TB) is a common form of extrapulmonary TB (EXPTB). It is being reported increasingly, especially in high-burden regions of the world. We present a case of a 37-year-old male who presented to the emergency department with clinical features suggestive of bowel obstruction. On clinical examination, the patient exhibited generalized tenderness in the abdomen. A subsequent CT scan revealed features consistent with small bowel obstruction. The patient underwent a diagnostic laparoscopy, which was converted to an exploratory laparotomy due to intraoperative findings of adhesions. Notably, there were extensive peritoneal deposits and adhesions between bowel loops. Peritoneal biopsies were obtained and subjected to the acid-fast bacillus (AFB) smear and culture, which demonstrated the growth of the Mycobacterium tuberculosis complex. As a result, the patient was initiated on antituberculous therapy.

The Role of Point-of-Care Ultrasound in Pilonidal Sinus Disease.

Pilonidal sinus is a common problem encountered in proctology clinics. It has a wide spectrum of clinical picture ranging from a single asymptomatic pit to a more complex disease with multiple sinuses and secondary openings. Hence, the treatment options could range from observation or simple excision to a more radical approach like flap surgeries. Ultrasonographic assessment could help in mapping the extent of the pilonidal sinus. It can also identify whether the sinus is infected or has formed an abscess. With the above-mentioned information provided by the point of care ultrasound, the surgeon can tailor the surgical approach to each individual case and improve the overall outcome. In this article, we are highlighting some examples of cases managed in our proctology unit where ultrasound was done preoperatively and guided the management.

Phytobezoar impaction in a Meckel's diverticulum; a rare cause of bowel obstruction: Case report and review of literature.

INTRODUCTION: Meckel's diverticulum is the most common anomaly of the gastrointestinal tract, occurring in 1-3% of the general population. The most common complication of Meckel's diverticulum is intestinal obstruction. In this report, we describe a rare cause of intestinal obstruction due to Meckel's; the phytobezoar. After thorough literature review, the authors found about ten individual reports of the same topic. In all these cases, diagnosis was established intra-operatively. CASE PRESENTATION: A forty-seven-year old male presented to the emergency department with a one-day history of abdominal pain associated with vomiting and constipation. Physical examination diagnostic tests revealed features of intestinal obstruction. DISCUSSION: The lifetime risk of complications in patients with a Meckel'sdiverticulum is usually small and occurs only in up to 4%. In adults' intestinal obstruction is the most common complication (40%). CONCLUSION: Complicated Meckel's diverticulum can have different clinical presentations and can cause bowel obstruction. An association with bezoars impaction is possible and it should be suspected in adult patients presenting with bowel obstruction of unknown causes especially those with high vegetarian diet.

Superior mesenteric artery syndrome: A diagnosis to be kept in mind (Case report and literature review).

INTRODUCTION: Superior mesenteric artery (SMA) syndrome or what is called Wiklie's syndrome is one of the rare causes of small bowel obstruction. Its exact incidence is not known. It is due to decrease in Aortomesenteric angle. CASE PRESENTATION: A thirty-Four-year old male patient presented to our accident and emergency (department) with 3days history of epigastric pain, which was not radiating anywhere. It had no aggravating or relieving factors. Patient complained of repeated attack of vomiting as well. Contrast enhanced Computed tomography (CT) showed duodenal obstruction caused by superior mesenteric artery compression on 3rd part of duodenum. DISCUSSION: Superior mesenteric artery syndrome (SMA) is one of the rare causes of small bowel obstruction. Incidence of superior mesenteric artery syndrome reported in literature is ranging from 0.1 to 0.3%. The most common cause is significant weight loss which leads to loss of retroperitoneal fat. Treatment usually is conservative but surgical intervention should be considered if that failed. CONCLUSION: Superior mesenteric artery syndrome is a rare cause of intestinal obstruction but should be kept in mind. Persistent vomiting after history of weight loss should raise the suspicion of this diagnosis. Upper GI endoscopy may be necessary to exclude mechanical causes of duodenal obstruction. Contrast enhanced CT scan is useful in the diagnosis of superior mesenteric artery syndrome and can provide diagnostic information.

Traumatic Jejunal hematoma in childhood-A case report and review of literature.

INTRODUCTION: Intramural jejunal hematoma is a very rare condition with only few cases reported in the literature. It rarely occurs spontaneously, and is mostly seen in hemophiliac patients and is also associated with abdominal trauma. It occurs more commonly in children than in adults and can present with features of intestinal obstruction. CASE PRESENTATION: A 10year old boy presented with features of intestinal obstruction. He sustained a blunt abdominal trauma two days prior to presentation. Abdominal computed tomography (CT) revealed jejunal hematoma with signs of complete obstruction. A trial of non-operative management failed and eventually he was managed surgically. DISCUSSION: Blunt trauma to the abdomen is the principle cause of jejunal hematoma. The trauma in majority of cases is trivial and usually the patients present late. The symptoms range from mild abdominal pain to intestinal obstruction with acute abdomen. A trial of conservative management is justifiable in stable patient. If no clinical improvement surgical intervention is indicated. CONCLUSION: Intramural jejunal hematoma after blunt abdominal trauma is seen predominately in pediatric age group and can present as intestinal obstruction. It should be suspected when a child presents with intestinal obstruction and a concurrent history of blunt abdominal trauma. The mainstay of treatment is surgical intervention. Because of the rarity of this disease, the role of conservative therapy is undefined.

Seat belt syndrome: Delayed or missed intestinal injuries, a case report and review of literature.

INTRODUCTION: Seat belt injuries are not uncommon. The use of seat belts is associated with a unique injury profile collectively termed "the seat belt syndrome". The aim is to aid in the early diagnosis of seat belt injuries. CASE PRESENTATION: Two different patients presented to the emergency after sustaining a motor vehicle accident. Both were the drivers, restrained and had a frontal impact. On presentation they were hemodynamically stable with mild tenderness on the abdomen and the abdominal computed tomography (CT) did not show any signs of bowel or mesenteric injuries. The signs of peritonitis became obvious after 24h in one case and after 3 days in the other. DISCUSSION: Early diagnosis provides better outcomes for patients with seat belt injuries, but this remains a challenge to trauma surgeons. The typical findings of peritonitis might not be present initially. The presence of abdominal wall ecchymosis (seat belt sign) increases the chance of intraabdominal injuries by eight folds. CONCLUSION: Clinical signs of intestinal injuries might not be obvious on presentation. In the presence of seat belt sign the possibility of bowl injury must be suspected. Admit the patient for observation even if no clinical or radiological findings are present at presentation.

Spontaneous rupture of the urinary bladder (SRUB); A case report and review of literature.

INTRODUCTION: Spontaneous urinary bladder rupture is a rare urological emergency. It is usually secondary to an underlying pathology and it is an uncommon complication of urosepsis. We report a case of spontaneous urinary bladder rupture as a complication of urosepsis in a 67 year old male patient, who was admitted as a case of left diabetic foot and urinary tract infection. CASE PRESENTATION: A 67 year old male patient with a long standing indwelling urinary catheter and chronic cystitis developed acute peritonitis. Intraoperative finding was ruptured urinary bladder. DISCUSSION: A few cases of spontaneous urinary bladder rupture due to infection were found in literature. The majority of the patients present with diffuse abdominal pain, and tenderness due to chemical peritonitis. In the majority of cases the bladder perforation was diagnosed intra-operative. CONCLUSION: A diagnosis of spontaneous perforation of the bladder should be considered in patients presenting with an acute abdomen. The general surgeon is more likely than the urologist to encounter such patients in the first instance. There should be a high index of suspicion in patients with an acute abdomen and have associated urinary bladder condition.

The Gatekeeper™ for fecal incontinence: Another trial and error.

INTRODUCTION: The Gatekeeper™ is the most recent bulking agent used in the treatment of fecal incontinence with no reported complications. This case reports side effects similar to other bulking agents, namely migration of the prosthesis and perianal abscess. PRESENTATION OF CASE: A 52 year old gentleman presented with a history of fecal soiling. He underwent uncomplicated surgery in 2012 for 6 Gatekeeper™ implantations with only temporary improvements. In 2013, endorectal ultrasound revealed prosthesis migration. In 2014, he presented with a perianal abscess which contained one of the prosthesis. DISCUSSION: The Gatekeeper™, made of the inert Hyexpan, typically implanted in the intersphincteric region, has been used for the treatment of fecal incontinence since its discontinuation in the treatment of gastroesophageal reflux disease.(5) The Gatekeeper™ was implemented on a small number of subjects for which the typical side effects of bulking agents were not seen. CONCLUSION: Larger studies need to be conducted to investigate the advantages or perhaps disadvantages of the Gatekeeper™ over other bulking agents.

Colorectal injury by compressed air: the rule of conservative therapy / Lesão colorretal por ar comprimido: a regra da terapia conservadora

ABSTRACT We are reporting a case of colorectal injury caused by a jet of compressed air directed from a distance towards the anus. The patient mentioned that it happened accidentally while his colleague was cleaning his clothes using compressed air. The patient presented with acute abdominal pain and distension. A contrast CT study did not show any free air or leakage. The patient was treated conservatively, progressed well and was discharged from the hospital on the fourth day.

RESUMO Descrevemos um caso de lesão colorretal causada por um jato de ar comprimido direcionado para o ânus, a certa distância. O paciente mencionou que o ocorrido foi acidental, enquanto um colega estava limpando suas roupas com ar comprimido. O paciente se apresentou com dores abdominais agudas e distensão. Um estudo de TC contrastado não demonstrou ar livre, nem vazamento. O paciente foi tratado conservadoramente, teve boa evolução e recebeu alta hospitalar no quarto dia.

Anal fistula surgery in an outpatient setting: the Dubai experience / Cirurgia de fístula anal em regime ambulatorial: a experiência Dubai

AIM: To determine whether surgery for transsphincteric and complex fistula-in-ano can be performed safely as a day case. METHOD: This is a retrospective study of 66 patients with transsphincteric and complex anal fistulas, initially managed with preliminary loose Seton followed by fistulectomy and sphincter repair 2-4 months later between March 2011 and March 2014. Patients were seen at the clinic 1 week, 3 months and 1 year post-operatively and were observed for complications and recurrences; incontinence was noted down and was graded according to the Cleveland Clinic score. RESULT: Twenty-five patients (38%) had high or complex fistulas and 32 (48.5%) had a history of previous surgery. All cases were done in an outpatient setting. The Seton was kept in situ for 2-5 months (2.6 months) followed by fistulectomy and sphincter repair. Complete healing was achieved within approximately 3.6 weeks (2-8 weeks). Fifty-one patients were followed up successfully for one year. Two patients had temporary flatus incontinence which had resolved over 2-3 months. Recurrence had occurred in 2 (3.9%) patients. CONCLUSION: Transsphincteric and complex fistulas can safely be operated on as day case surgeries with high patient satisfaction and less complication in the population we studied. (AU)

OBJETIVO: Determinar se cirurgias para fístulas transesfincterianas e para fistulae in ano complexas podem ser realizadas com segurança em ambiente ambulatorial, sem pernoite do paciente no hospital. MÉTODO: Trata-se de um estudo retrospectivo de 66 pacientes com fístulas transesfincterianas e fístulas anais complexas, inicialmente tratados preliminarmente com seton de drenagem, seguido por fistulectomia e reparo do esfíncter 2-4 meses mais tarde, entre março de 2011 e março de 2014. Os pacientes foram reexaminados no ambulatório uma semana, três meses e ano após a cirurgia, tendo sido observados para complicações e recorrências; casos de incontinência foram anotados e classificados de acordo com o escore da Cleveland Clinic. RESULTADO: Vinte e cinco pacientes (38%) apresentaram fístulas altas ou complexas e 32 (48,5%) tinham história de cirurgia prévia. Todos os casos foram tratados em ambiente ambulatorial. O seton foi mantido in situ durante 2-5 meses (2,6 meses), seguido por fistulectomia e reparo do esfíncter. A cura completa se concretizou em cerca de 3,6 semanas (2-8 semanas). Cinquenta e um pacientes foram acompanhados com sucesso ao longo de um ano. Dois pacientes tiveram incontinência temporária para gases, resolvida ao longo de 2-3 meses. Recorrência ocorreu em 2 (3,9%) pacientes. CONCLUSÃO: Fístulas transesfincterianas e fístulas complexas podem ser operadas com segurança como casos ambulatoriais, sem permanência hospitalar noturna, com grande satisfação do paciente e menos complicações na população estudada. (AU)