Obturator hernia: An uncommon cause of intestinal obstruction: A case report.

INTRODUCTION AND IMPORTANCE: An obturator hernia is a rare cause of bowel obstruction. Due to its narrow passage in the obturator canal, these are more susceptible to becoming incarcerated and subsequently strangulated. Due to its challenging detection, obturator hernia is often diagnosed late. CASE PRESENTATION: A 75-year-old thin-built female with COPD presented to the emergency room with symptoms of abdominal obstruction. Abdominal examination revealed distension, firmness, rigidity, and tenderness with no bowel sounds. An erect abdominal X-ray showed multiple air-fluid levels, indicating an acute abdomen due to intestinal obstruction. Emergency exploratory laparotomy revealed an obturator hernia with strangulated ileum and perforation, necessitating resection and double barrel ileostomy. Unfortunately, despite all medical interventions, the patient succumbed to hospital-acquired pneumonia following the surgery. DISCUSSION: Obturator hernia, known as 'the skinny old woman hernia,' is rarely externally visible or palpable, leading to frequent undiagnosed cases. It presents with bowel obstruction or perforation and carries the highest morbidity among abdominal hernias. Timely intervention is crucial to prevent complications like bowel strangulation. CONCLUSION: This case report highlights the challenges of diagnosing and managing obturator hernia, a rare condition with significant morbidity. Early detection through imaging or operative findings is crucial to prevent complications like bowel strangulation, especially in older women at higher risk.

Systemic postnatal corticosteroid use for the prevention of bronchopulmonary dysplasia and its relationship to early neurodevelopment in extremely preterm infants.

BACKGROUND: Systemic postnatal corticosteroid use in extremely preterm infants poses a risk of adverse neurodevelopmental outcomes. This study explores their use beyond seven days of age with early neurodevelopmental assessments during the fidgety period (9-20 weeks postterm age). METHODS: This retrospective single-center cohort study included inborn extremely preterm infants from 1 January 2014 to 31 December 2018. Outborn infants, those with congenital or genetic abnormalities, and those who received postnatal corticosteroids for nonrespiratory reasons were excluded. The cohort was dichotomized based on the status of corticosteroid receipt. Early neurodevelopmental outcomes were reported using Prechtl's General Movements Assessment. RESULTS: Of the 282 infants, 67 (23.75%) received corticosteroids. Of these, 34 (50.75%) received them for dependency on invasive ventilation (intermittent positive-pressure ventilation), and the remainder received them for dependency on non-invasive ventilation continuous positive airway pressure (CPAP) or bi-level positive airway pressure (BiPAP). Abnormal or absent fidgety movements were observed in 13% of infants (7/54) who received corticosteroids compared to 2% of infants (3/146) who did not. An increased odds for an abnormal general movements assessment from corticosteroid use after adjusting for gestational age [adjusted odds ratio (aOR) = 5.5, 95% confidence interval (CI) = 1.14-26.56] was observed. The motor optimality scores differed between the two groups [corticosteroid group: 25.5 (23-26) versus no-corticosteroid group: 26 (24-28); z = - 2.02]. A motor optimality score < 20 was observed in 14.8% of infants (8/54) in the corticosteroid group compared to 2% of infants (3/146) in the noncorticosteroid group. This difference was significant after adjustment for gestational age (aOR 5.96, 95% CI 1.28-27.74). CONCLUSIONS: Abnormal early neurodevelopment was observed in infants who received systemic postnatal corticosteroids. The relationship between these findings and other factors influencing early neurodevelopment needs further exploration.

Effect of H. pylori density by histopathology on its complications and eradication therapy.

INTRODUCTION: Helicobacter pylori (H. pylori) infection causes chronic gastritis and is a major risk factor for duodenal and gastric ulceration, gastric adenocarcinoma, and primary gastric lymphoma. Increased gastric bacterial density may lead to increased levels of inflammation and epithelial injury. AIMS AND OBJECTIVES: 1) To study the effect of H. pylori density by histological changes in stomach. 2) To study the effect of H. pylori density on the efficacy of standard triple drug eradication treatment. 3) To study the effect of H. pylori density on the complication related to H. pylori. MATERIAL AND METHODS: All the patients visiting gastroenterology OPD with the symptoms of dyspepsia not responding to proton pump inhibitor or having alarm symptoms were subjected to upper GI endoscopy and biopsy. If H. pylori was present they were included in the study. The patients were given standard 14 day triple antibiotic combination for H. pylori eradication. H. pylori eradication was confirmed by urea breath test after six weeks of completion of treatment. RESULTS: Out of 250 patients screened, 120 patients enrolled in the study. On clinical history 41.5% patients had symptoms of heart burn where as 63.3% patients had dyspeptic symptoms. Success rate of anti H. pylori triple drug therapy was 80%. Rate of eradication was significantly lower among the patients with higher H. pylori density (p < 0.05) on histopathology by Sydney classification. Duodenal ulcer, Gastric ulcer and gastric erosion were noted in higher frequencies among the patients with higher H. pylori density (p < 0.05). CONCLUSION: H. pylori density by histopathology correlates with the complication related to H. pylori i.e. duodenal ulcer, reflux esophagitis and antral erosions. It also correlates with the success of the standard triple drug eradication treatment.

Biliary sphincteroplasty facilitates retrieval of proximally migrated plastic biliary stent.

BACKGROUND AND AIM: Proximal migration of biliary stents presents a technical challenge for the therapeutic endoscopist. It may require multiple, complicated corrective procedures resulting in significant morbidity to the patients. In this study we evaluated the utility of balloon biliary sphincteroplasty with CRE (Controlled Radial Expansion) Balloon Dilator on retrieval of proximally migrated biliary stents. METHODS: We identified patients from our ERCP database who presented with proximal migration of biliary stent, between August 2011 and October 2013. Patients in whom the stent could not be retrieved with conventional methods, balloon sphincteroplasty was performed with a 12 mm CRETM Balloon Dilator (Boston Scientific). Stent removal was attempted with extraction balloon or basket thereafter. RESULTS: We identified 28 patients with proximal migration of biliary stents, placed for benign diseases of the common bile duct. Stent removal was successful in 18 patients (64.28%) with help of an extraction balloon or basket. Of the remaining 10 patients, balloon sphincteroplasty was successfully followed by stent removal in eight patients. CONCLUSIONS: Balloon biliary sphincteroplasty increases the success rate of retrieving proximally migrated biliary stents. The procedure is safe, technically easy and yields a good success rate in our experience.

Esophageal tuberculosis presenting with hematemesis.

Esophageal tuberculosis is rare, constituting about 0.3% of gastrointestinal tuberculosis. It presents commonly with dysphagia, cough, chest pain in addition to fever and weight loss. Complications may include hemorrhage from the lesion, development of arterioesophageal fistula, esophagocutaneous fistula or tracheoesophageal fistula. There are very few reports of esophageal tuberculosis presenting with hematemesis due to ulceration. We report a patient with hematemesis that was due to the erosion of tuberculous subcarinal lymph nodes into the esophagus. A 15-year-old boy presented with hemetemesis as his only complaint. Esophagogastroduodenoscopy (EGD) revealed an eccentric ulcerative lesion involving 50% of circumference of the esophagus. Biopsy showed caseating epitheloid granulomas with lymphocytic infiltrates suggestive of tuberculosis. Computerised tomography of the thorax revealed thickening of the mid-esophagus with enlarged mediastinal lymph nodes in the subcarinal region compressing the esophagus along with moderate right sided pleural effusion. Patient was treated with anti-tuberculosis therapy (Rifampicin, Isoniazid, Pyrazinamide, Ethambutol) for 6 mo. Repeat EGD showed scarring and mucosal tags with complete resolution of the esophageal ulcer.

Uncomplicated spontaneous rupture of pancreatic pseudocyst into stomach: A case report.

Pseudocysts of the pancreas are not rare, but spontaneous perforation and/or fistulization occurs in fewer than 3% of these pseudocysts. Perforation into the free peritoneal cavity, stomach, duodenum, colon, portal vein, pleural cavity and through the abdominal wall has been reported. Spontaneous rupture of the pancreatic pseudocyst into the surrounding hollow viscera is rare and, may be associated with life-threatening bleeding. Such cases require emergency surgical intervention. Uncomplicated rupture of pseudocyst is an even rarer occurrence. We present a case of spontaneous resolution of a pancreatic pseudocyst with gastric connection without bleeding. A 67-year-old women with a large pancreatic pseudocyst resulting from a complication of chronic pancreatitis was referred to our institution. During hospital stay, there was sudden decrease in the size of epigastric lump. Repeat computed tomography (CT) revealed that the size of the pseudocyst had decreased significantly; however, gas was observed in stomach and pseudocyst along with rent between lesser curvature of stomach and pseudocyst suggestive of spontaneous cystogastric fistula.The fistula tract occluded spontaneously and the patient recovered without any complication or need for surgical treatment. After 5 wk, follow up CT revealed complete resolution of pseudocyst. Esophagogastroduodenoscopy revealed that the orifice was completely occluded with ulcer at the site of previous fistulous opening.

Antibiotic regimens for the empirical treatment of newborn infants with necrotising enterocolitis.

BACKGROUND: Although the exact aetiology of necrotising enterocolitis (NEC) remains unknown, research suggests that it is multifactorial; suspected pathophysiological mechanisms include immaturity, intestinal ischaemia, disruption of intestinal mucosal integrity, formula feeding, hyperosmolar load to the intestine, infection and bacterial translocation. Various antibiotic regimens have been widely used in the treatment of NEC. OBJECTIVES: To compare the efficacy of different antibiotic regimens on mortality and the need for surgery in neonates with NEC. SEARCH METHODS: Searches were made of the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 1, 2012), Oxford Database of Perinatal Trials, MEDLINE (1966 to February 2012), EMBASE (1980 to February 2012) and CINAHL (1982 to February 2012). SELECTION CRITERIA: All randomised and quasi-randomised controlled trials where antibiotic regimens were used for treatment of NEC. DATA COLLECTION AND ANALYSIS: Eligibility of studies for inclusion was assessed independently by each review author. The criteria and standard methods of the Cochrane Neonatal Review Group were used to assess the methodological quality of the included trials. MAIN RESULTS: Two trials met the inclusion criteria. Faix 1988 randomised 42 premature infants with radiological diagnosis of NEC. Infants were randomised to receive either intravenous ampicillin and gentamicin or ampicillin, gentamicin and clindamycin. Hansen 1980 randomised 20 infants with NEC to receive intravenous ampicillin and gentamicin with or without enteral gentamicin.In the study by Faix 1988, there were no statistical differences in mortality (RR 1.10; 95% CI 0.32 to 3.83) or bowel perforation (RR 2.20; 95% CI 0.45 to 10.74) between the two groups although there was a trend towards higher rate of strictures in the group that received clindamycin (RR 7.20; 95% CI 0.97 to 53.36).The Hansen 1980 study showed no statistically significant difference in death, bowel perforation or development of strictures. AUTHORS' CONCLUSIONS: There was insufficient evidence to recommend a particular antibiotic regimen for the treatment of NEC. There were concerns about adverse effects following the usage of clindamycin, related to the development of strictures. To address this issue a large randomised controlled trial needs to be performed.