Intestinal ascariasis in children.

BACKGROUND: Ascariasis is a staggering health problem commonly seen in children of endemic areas. In the abdomen, ascaris lumbricoides can cause a myriad of surgical complications. Intestinal obstruction by ascaris lumbricoides is commonly seen in children. Most cases are managed conservatively. The purpose was to study the clinical presentation and management of symptomatic intestinal ascariasis in children. METHODS: A 3-year study was performed from April 2006 to April 2009 of pediatric-age patients who had symptomatic intestinal ascariasis. All patients had detailed clinical history, examination, plain X-ray of abdomen, and ultrasonography of abdomen. Peroperative findings were recorded in all patients who had surgical intervention. RESULTS: This prospective study had 360 patients. Male to female ratio was 1.37:1. 187 patients (52%) presented within 2-4 days of duration of illness. Mean +/- standard deviation (SD) age of patients was 6.35 +/- 2.25 years. Age group of 4-7 years (80%) was commonest group affected. Abdominal pain was a leading symptom in 357 patients (99%) with the pain in periumbilical area present in 215 patients (60%). In 227 patients (63%) abdominal distension was seen and was the commonest physical finding. Palpable worm masses were seen in 129 patients (36%); 81 patients (63%) had palpable worm masses in the umbilical quadrant. On X-ray of abdomen, visible worm masses were seen in 83 patients (23%). Abdominal sonography showed interloop fluid in 177 patients (49%) and free fluid in the pelvis of 97 patients (27%). The number of patients who were managed conservatively was 281 (78%), and 79 patients (22%) had surgical intervention. In patients who had surgical intervention, 39 patients (49%) had enterotomy and 7 patients (9%) had kneading of worms. Postoperative complications occurred in 33 patients, and an overall mortality of 1% (1 patient) was seen. CONCLUSIONS: Ascaridial intestinal obstruction is common in children in the Kashmir. Abdominal pain is the leading symptom in intestinal ascariasis. Plain X-ray and ultrasonography of the abdomen are used to diagnosis intestinal ascariasis. The majority of the patients can be managed conservatively.

Study of Surgical Emergencies of Tubercular Abdomen in Developing Countries.

To study the various modes of presentation, diagnosis, and management of surgical emergencies of tubercular abdomen. This prospective study of surgical emergencies of tubercular abdomen was conducted in 50 patients who attended our surgical emergency from 2006 to 2008. Patients were evaluated thoroughly with history, physical examination, routine investigations, and special investigations such as ELISA, PCR, barium studies of gastrointestinal tract, and diagnostic laparoscopy as required and managed with medical and surgical treatment as necessary. The most of patients were from rural areas, in the third to sixth decades with slight male preponderance. Abdominal pain, vomiting, and constipation were commonest presenting symptoms. About 20 % patients had history of pulmonary tuberculosis and 16 % patients presented with ascites. PCR for blood and ascitic fluid was positive in 72 and 87.5 % patients, respectively. About 24 % patients were managed nonoperatively and responded to ATT. About 76 % patients needed surgery among which one-fifth of patients were operated in emergency. Procedures like adhesiolysis of gut (47.3 %), strictureplasty (10.5 %), resection anastomosis (5.2 %), right hemicolectomy (5.2 %), and ileotransverse anastomosis (7.8 %) were performed in 30 patients and peritoneal biopsy and lymph node biopsy in the remaining 8 patients. Both medically and surgically managed patients were put on antitubercular therapy. Abdominal tuberculosis is a disease of middle-aged rural people, presenting commonly with abdominal pain and vomiting with right lower abdominal tenderness. PCR (blood and ascites) for tuberculosis is much more sensitive than IgM ELISA (blood and ascites). The most of patients required surgical procedures and all patients responded dramatically to antitubercular therapy symptomatically with increase in the hemoglobin level and decrease in ESR.

Giant mastoid emissary vein: source of profuse bleeding during mastoid surgery.

The emissary veins are residual connections between intra-cerebral veins and their extra-cranial drainage. Mastoid emissary vein is a rare but definite entity which if not diagnosed preoperatively could be a cause of severe hemorrhage at the time of surgery which may prove to be life threatening. These veins may vary in size from that of a mere thread to that of a wax match or 1/8th-3/8th of an inch. We report one such case of a giant mastoid emissary vein which was opened while operating on mastoid and caused profuse bleeding which could only be controlled by surgical pack.

Ruptured heterotopic pregnancy: a rare cause for hemoperitoneum; report of three cases from kashmir, India.

Heterotopic pregnancy has been found in various forms but is still a rare event in the natural conception cycles, occurring in less than 1:30000 pregnancies with the incidence rising to 1:100 to 1:500 pregnancies duo to assisted reproductive technologies. Delay in diagnosing the condition can be fatal for both the mother and the fetus. Three patients aged 28, 31 and 26 years presented with amenorrhea of ten, eight and twelve weeks duration respectively with signs of peritonism and shock. Investigations revealed intra and extra uterine pregnancies in all the three cases with the rupture of the extra uterine pregnancies. All the cases were operated and first two cases were followed up postoperatively till the delivery of the term live babies. The third case is still under our follow up. A high index of suspicion by a general surgeon is needed in arriving at a prompt diagnosis of ruptured heterotopic pregnancy so that rapid resuscitation, heart sparing anesthesia and expeditious surgery is carried out for both maternal and intrauterine fetal wellbeing.

Encountering Meckel's diverticulum in emergency surgery for ascaridial intestinal obstruction.

BACKGROUND: Meckel's diverticulum is the most common congenital anomaly of the gastrointestinal tract. In children with intestinal ascariasis, the diverticulum remains asymptomatic or rarely the Ascaris lumbricoides may lead to its complications in the presence of massive intestinal roundworm load. Given that preoperative diagnosis is seldom carried out, when Meckel's diverticulum is found at laparotomy for obstructive intestinal complications of roundworm, the diverticulum should be removed as complications may occur at any time. The aim of this study was to describe the findings of concomitant presence of Meckel's diverticulum who had surgical intervention in symptomatic intestinal ascariasis in children. METHODS: A retrospective case review study of 14 children who had surgical intervention for symptomatic intestinal ascariasis having the presence of concomitant Meckel's diverticulum was done. The study was done at SMHS Hospital Srinagar, Kashmir. RESULTS: A total of the 14 children who had ascaridial intestinal obstruction with concomitant presence of Meckel's diverticulum were studied. Age of children ranged from 4-12 years, male:female ratio was 1.8:1. Nine patients had asymptomatic Meckel's diverticulum, whereas 5 patients with symptomatic signs were found in the course of emergency surgery for ascaridial intestinal obstruction. CONCLUSION: Meckel's diverticulum in intestinal ascariasis may pursue silent course or may be accompanied with complications of the diverticulitis, perforation or the gangrene. Incidental finding of the Meckel's diverticulum in the intestinal ascariasis should have removal.