Subject(s)
Clinical Decision-Making/methods , Conservative Treatment/methods , Digestive System Surgical Procedures/methods , Diverticulum , Duodenal Diseases , Intestinal Perforation , Tomography, X-Ray Computed/methods , Aged, 80 and over , Anti-Bacterial Agents/administration & dosage , Diagnosis, Differential , Diverticulum/complications , Diverticulum/diagnostic imaging , Drainage/methods , Duodenal Diseases/complications , Duodenal Diseases/diagnostic imaging , Endoscopy, Digestive System/methods , Humans , Intestinal Perforation/diagnosis , Intestinal Perforation/physiopathology , Intestinal Perforation/therapy , Male , Parenteral Nutrition, Total/methods , Risk Adjustment/methods , Risk Assessment , Rupture, Spontaneous/diagnosis , Rupture, Spontaneous/physiopathology , Rupture, Spontaneous/therapy , Treatment OutcomeABSTRACT
BACKGROUND: Gallstone disease is a burden affecting about 15% percent of the population around the world. The complications of gallstone disease are numerous and many require emergency care. Severe complications are not uncommon and require special attention, as lethal outcome is possible. CASE PRESENTATION: We present a retrospective analysis of eight cases describing severe complications of gallstones in patients undergoing endoscopic treatment of chronic gallstones conditions. All patients were admitted to our emergency care department following symptoms onset. The diagnostic difficulties, treatment strategies and outcomes are presented. The associated risk factors and preventative measures are discussed. Two patients developed profuse bleeding, two developed acute pancreatitis, two patients had perforation related complications. One rare case of bilioma and one case of iatrogenic injury are presented. All patients had severe condition, in two cases lethal outcome was a result of co-morbidity and difficulties in management. CONCLUSION: Special care should be taken in patients with risk factors of severe complications in order to improve outcome and prevent the development of life-threatening conditions.
Subject(s)
Cholangiopancreatography, Endoscopic Retrograde , Cholecystectomy, Laparoscopic , Cholelithiasis/surgery , Postoperative Complications/therapy , Sphincterotomy, Endoscopic , Adult , Aged , Biliary Fistula/physiopathology , Biliary Fistula/therapy , Chronic Disease , Common Bile Duct/injuries , Duodenal Diseases/physiopathology , Duodenal Diseases/therapy , Emergency Service, Hospital , Female , Gallstones/surgery , Gastrointestinal Hemorrhage/physiopathology , Gastrointestinal Hemorrhage/therapy , Humans , Iatrogenic Disease , Intestinal Perforation/physiopathology , Intestinal Perforation/therapy , Male , Middle Aged , Pancreatitis/physiopathology , Pancreatitis/therapy , Portal Vein , Postcholecystectomy Syndrome , Postoperative Complications/physiopathology , Vascular Fistula/physiopathology , Vascular Fistula/therapySubject(s)
Abdominal Pain , Biliary Atresia , Foreign Bodies , Intestinal Perforation , Intestine, Small , Portoenterostomy, Hepatic , Abdominal Pain/diagnosis , Abdominal Pain/etiology , Abdominal Pain/surgery , Adult , Bile Ducts/abnormalities , Biliary Atresia/etiology , Biliary Atresia/surgery , Diagnosis, Differential , Digestive System Surgical Procedures/methods , Female , Foreign Bodies/diagnosis , Foreign Bodies/physiopathology , Foreign Bodies/surgery , Foreign-Body Migration/complications , Humans , Hypertension, Portal/diagnosis , Hypertension, Portal/etiology , Intestinal Perforation/etiology , Intestinal Perforation/physiopathology , Intestinal Perforation/surgery , Intestine, Small/injuries , Intestine, Small/surgery , Portoenterostomy, Hepatic/adverse effects , Portoenterostomy, Hepatic/methods , Tomography, X-Ray Computed/methods , Treatment OutcomeABSTRACT
The COVID-19 pandemic has recently spread worldwide, presenting primarily in the form of pneumonia or other respiratory disease. In addition, gastrointestinal manifestations have increasingly been reported as one of the extrapulmonary features of the virus. We report two cases of SARS-CoV-2 infection complicated by paralytic ileus. The first patient was a 33-year-old man who was hospitalized with severe COVID-19 pneumonia requiring ventilator support and intensive care. He developed large bowel dilatation and perforation of the mid-transverse colon, and underwent laparotomy and colonic resection. Histopathology of the resected bowel specimen showed acute inflammation, necrosis, and hemorrhage, supporting a role for COVID-19-induced micro-thrombosis leading to perforation. The second patient was a 33-year-old man who had severe COVID-19 pneumonia, renal failure, and acute pancreatitis. His hospital course was complicated with paralytic ileus, and he improved with conservative management. Both cases were observed to have elevated liver transaminases, which is consistent with other studies. Several authors have postulated that the angiotensin-converting enzyme 2 receptors, the host receptors for COVID-19, that are present on enterocytes in both the small and large bowel might mediate viral entry and resultant inflammation. This is a potential mechanism of paralytic ileus in cases of severe COVID-19 infection. Recognizing paralytic ileus as a possible complication necessitates timely diagnosis and management.
Subject(s)
Betacoronavirus/pathogenicity , Coronavirus Infections/virology , Intestinal Perforation/virology , Intestinal Pseudo-Obstruction/virology , Pancreatitis/virology , Pneumonia, Viral/virology , Renal Insufficiency/virology , Adult , Biomarkers/metabolism , COVID-19 , Coronavirus Infections/diagnostic imaging , Coronavirus Infections/physiopathology , Coronavirus Infections/therapy , Humans , Intestinal Perforation/diagnostic imaging , Intestinal Perforation/physiopathology , Intestinal Perforation/therapy , Intestinal Pseudo-Obstruction/diagnostic imaging , Intestinal Pseudo-Obstruction/physiopathology , Intestinal Pseudo-Obstruction/therapy , Liver/enzymology , Liver/pathology , Liver/virology , Male , Pancreatitis/diagnostic imaging , Pancreatitis/physiopathology , Pancreatitis/therapy , Pandemics , Pneumonia, Viral/diagnostic imaging , Pneumonia, Viral/physiopathology , Pneumonia, Viral/therapy , Positive-Pressure Respiration/methods , Renal Dialysis , Renal Insufficiency/diagnostic imaging , Renal Insufficiency/physiopathology , Renal Insufficiency/therapy , SARS-CoV-2 , Tomography, X-Ray Computed , Transaminases/metabolismABSTRACT
A rare case of malignant Brenner tumour of ovary manifesting with intestinal perforation due to colonic infiltration is elaborated in the present report. Brenner's tumour accounts for 1%-2% of all ovarian neoplasms and malignant Brenner tumour is even rarer and only about 5% of Brenner tumours are malignant. A 62-year-old woman came to surgical emergency with 1-month history of abdominal pain, vomiting and constipation with a palpable mass in right iliac fossa. Abdominal radiograph was suggestive of colonic obstruction. Contrast-enhanced CT of the abdomen revealed cystic right ovarian mass of 10.2×8.8 cm2 with pneumoperitoneum. Exploratory laparotomy was done, which revealed mass arising from right ovary involving terminal ileum, cecum and ascending colon. Possibility of ovarian malignancy was kept. Patient underwent debulking surgery along with ileostomy and descending colon mucous fistula was created. Histology was compatible with malignant Brenner tumour of the ovary.
Subject(s)
Brenner Tumor , Critical Care/methods , Cytoreduction Surgical Procedures , Intestinal Obstruction , Intestinal Perforation , Ovarian Neoplasms , Brenner Tumor/pathology , Brenner Tumor/surgery , Colon/diagnostic imaging , Colon/pathology , Constipation/diagnosis , Constipation/etiology , Cytoreduction Surgical Procedures/methods , Diagnosis, Differential , Fatal Outcome , Female , Humans , Intestinal Obstruction/diagnosis , Intestinal Obstruction/etiology , Intestinal Obstruction/physiopathology , Intestinal Obstruction/surgery , Intestinal Perforation/diagnosis , Intestinal Perforation/etiology , Intestinal Perforation/physiopathology , Intestinal Perforation/surgery , Middle Aged , Neoplasm Invasiveness , Ovarian Neoplasms/pathology , Ovarian Neoplasms/surgery , Ovary/diagnostic imaging , Ovary/pathology , Radiography, Abdominal/methods , Surgically-Created Structures , Tomography, X-Ray Computed/methodsABSTRACT
Background: The aim of this study is the evaluation of clinical signs and outcomes of treatment in children under five years of age who underwent appendectomy because of acute appendicitis. Patients and Methods: From January 2009 until December 2018, 90 patients (54 boys and 36 girls) younger than five years of age, treated with appendectomy because of acute appendicitis, were included in this study. Patients were divided into two groups, depending on the intra-operative finding of non-perforated (Group I; n = 32) or perforated (Group II; n = 58) appendicitis. The groups were compared regarding demographic, clinical, and laboratory data and outcomes of treatment. Results: Of 1687 appendectomies in this period, 90 (5.3%) of them were performed in patients aged five years or younger. There were 58 (64.4%) patients with perforated appendix. Positive correlation between the rate of perforation and the age of patients was found. Perforation rates were significantly higher in younger patients (100%, <1 year; 100%, 1-2 y; 83.3%, 2-3 y; 71.4%, 3-4 y; 78.6%, 4-5 y, and 47.3%, 5 y) (p = 0.037). Vomiting and diarrhea were found more commonly in the group of perforated appendix (p < 0.002, p < 0.001), while constipation was found more often in the patients whose appendix was not perforated (p < 0.001). The median duration of symptoms (48 h vs. 16 h; p < 0.001) and median duration of hospitalization (7.5 d vs. 5 d; p < 0.001) were notably longer for the group of patients with perforated than the group of patients with non-perforated appendix. All complications occurred in the group of perforated appendix with total incidence of 4.4%. Conclusion: The clinical presentation of acute appendicitis for children aged five years or younger is often unusual, and establishing the proper diagnosis is often delayed. Patient age is tied closely to the stage of acute appendicitis, so the youngest patients present with more advanced stages of disease and are at greater risk of perforation. Acute appendicitis should be considered in all cases where a child is having abdominal pain, fever, and diarrhea, which has been shown to be present significantly more often in children with perforated appendix.
Subject(s)
Appendectomy , Appendicitis/diagnosis , Delayed Diagnosis , Intestinal Perforation/diagnosis , Abdominal Pain/physiopathology , Age Factors , Anorexia/physiopathology , Appendicitis/complications , Appendicitis/physiopathology , Appendicitis/surgery , C-Reactive Protein/metabolism , Child, Preschool , Diarrhea/physiopathology , Female , Fever/physiopathology , Humans , Infant , Intestinal Perforation/etiology , Intestinal Perforation/physiopathology , Intestinal Perforation/surgery , Length of Stay , Leukocytosis , Male , Nausea/physiopathology , Retrospective Studies , Severity of Illness Index , Time Factors , Vomiting/physiopathologyABSTRACT
Although improved medical therapies have been associated with decreased rates of emergent intestinal resection for inflammatory bowel disease, prompt diagnosis and management remain of utmost importance to ensure appropriate patient care with reduced morbidity and mortality. Emergent indications for surgery include toxic colitis, acute obstruction, perforation, acute abscess, or massive hemorrhage. Given this broad spectrum of emergent presentations, a multidisciplinary team including surgeons, gastroenterologists, radiologists, nutritional support services, and enterostomal therapists are required for optimal patient care and decision making. Management of each emergency should be individualized based on patient age, disease type and duration, and patient goals of care.
Subject(s)
Colectomy/methods , Gastrointestinal Hemorrhage/surgery , Inflammatory Bowel Diseases/complications , Intestinal Obstruction/surgery , Intestinal Perforation/etiology , Intestinal Perforation/surgery , Abdomen, Acute/etiology , Abdomen, Acute/surgery , Anastomosis, Surgical , Colitis, Ulcerative/complications , Colitis, Ulcerative/diagnosis , Colitis, Ulcerative/therapy , Crohn Disease/complications , Crohn Disease/diagnosis , Crohn Disease/therapy , Emergencies , Female , Gastrointestinal Hemorrhage/etiology , Humans , Inflammatory Bowel Diseases/diagnosis , Intestinal Obstruction/etiology , Intestinal Obstruction/physiopathology , Intestinal Perforation/physiopathology , Male , Patient Care Team/organization & administration , Prognosis , Risk Assessment , Treatment OutcomeSubject(s)
Abdominal Abscess , Anastomosis, Surgical/methods , Cecum , Colectomy/methods , Crohn Disease/diagnosis , Foreign Bodies , Intestinal Perforation , Abdominal Abscess/diagnosis , Abdominal Abscess/etiology , Abdominal Abscess/surgery , Cecum/injuries , Cecum/surgery , Colonoscopy/methods , Foreign Bodies/complications , Foreign Bodies/surgery , Humans , Intestinal Perforation/complications , Intestinal Perforation/diagnosis , Intestinal Perforation/physiopathology , Intestinal Perforation/surgery , Male , Treatment Outcome , Young AdultABSTRACT
BACKGROUND: Spontaneous intestinal perforation (SIP) is an intestinal complication that occurs in very ill preterms. We investigated whether SIP survivors have worse neurodevelopmental and gastrointestinal outcomes and a poorer quality of life than controls. METHODS: A retrospective case-matched cohort study was performed involving infants treated for SIP in a NICU between August 1994 and April 2014. Controls and SIP patients were matched to gestational age, gender, and birth period. Medical records were reviewed. Telephone surveys were conducted to evaluate the medical condition, quality of life (PedsQL™ 4.0), neuropsychiatric and gastrointestinal outcome. McNemar's and Wilcoxon tests were performed, and generalized linear models were computed. RESULTS: Forty-nine SIP patients were included. The percentages of children with multiple disabilities (40% vs. 17%, ORâ¯=â¯3.3) and requiring physiotherapy (86% vs. 60%, ORâ¯=â¯4.77) were higher in the SIP group than in the control group. Intraventricular hemorrhage (IVH) led to a worse neurodevelopmental outcome regardless of SIP (ORâ¯=â¯8.79 for disability), and female gender was a protective factor against disability (ORâ¯=â¯0.06). Reported quality of life and gastrointestinal comorbidities did not differ between the two groups. CONCLUSION: SIP survivors tend to be at risk of multiple disabilities. IVH and female gender influence the neurodevelopmental outcome regardless of SIP. LEVELS OF EVIDENCE: Level III: case-control study.
Subject(s)
Infant, Newborn, Diseases , Infant, Very Low Birth Weight , Intestinal Perforation , Case-Control Studies , Developmental Disabilities , Female , Humans , Infant, Newborn , Infant, Newborn, Diseases/epidemiology , Infant, Newborn, Diseases/physiopathology , Infant, Newborn, Diseases/therapy , Intestinal Perforation/epidemiology , Intestinal Perforation/physiopathology , Intestinal Perforation/therapy , Male , Quality of Life , Retrospective Studies , Treatment OutcomeABSTRACT
AIM: The aim was to analyze the correlation between psoas muscle mass and mortality, as well as postoperative complications in patients treated for colonic perforation. PATIENTS AND METHODS: A total of 46 patients met the study criteria. Patients were classified into an elderly (age, ≥75 years, n=24) and a younger group (age, <75 years, n=22). Background factors, postoperative data (including duration of hospital stay and discharge) were collected. The cross-sectional area of the psoas muscle area (PMA) was measured on the same day of operation. RESULTS: The age/length of stay and PMA were significantly correlated in the younger group (p=0.0015, 0.023, respectively). Fifteen and six patients were discharged to return home, and 8 and 16 patients were transferred to another hospital, in the younger and elderly groups, respectively (p=0.02). Discharge was not correlated with the PMA in either group. CONCLUSION: The total psoas muscle mass would be useful as a quick and convenient measure of sarcopenia in younger patients, but not elderly patients.
Subject(s)
Colonic Neoplasms/surgery , Muscle, Skeletal/surgery , Sarcopenia/surgery , Adult , Aged , Aged, 80 and over , Colonic Neoplasms/diagnostic imaging , Colonic Neoplasms/pathology , Colonic Neoplasms/physiopathology , Cross-Sectional Studies , Female , Humans , Intestinal Perforation/physiopathology , Intestinal Perforation/surgery , Length of Stay , Male , Middle Aged , Muscle, Skeletal/diagnostic imaging , Muscle, Skeletal/physiopathology , Psoas Muscles/diagnostic imaging , Psoas Muscles/physiopathology , Psoas Muscles/surgery , Retrospective Studies , Sarcopenia/diagnostic imaging , Sarcopenia/physiopathology , Tomography, X-Ray ComputedSubject(s)
Enterocolitis, Necrotizing , Anti-Bacterial Agents/therapeutic use , Breast Feeding , Clinical Protocols , Digestive System Surgical Procedures/methods , Enterocolitis, Necrotizing/diagnosis , Enterocolitis, Necrotizing/physiopathology , Enterocolitis, Necrotizing/therapy , Erythrocyte Transfusion , Fluid Therapy , Humans , Infant, Low Birth Weight , Infant, Newborn , Infant, Premature, Diseases , Intestinal Perforation/diagnosis , Intestinal Perforation/physiopathology , Intestinal Perforation/surgery , Physical Examination/methods , Probiotics , Radiography, Abdominal/methodsSubject(s)
Abdominal Pain/diagnosis , Intestinal Perforation , Multiple Endocrine Neoplasia Type 1/complications , Point-of-Care Testing , Respiratory Distress Syndrome/diagnosis , Shock/diagnosis , Ultrasonography/methods , Zollinger-Ellison Syndrome , Abdominal Pain/etiology , Adult , Diagnosis, Differential , Endoscopy, Digestive System/methods , Gastrointestinal Tract/diagnostic imaging , Humans , Intestinal Perforation/diagnosis , Intestinal Perforation/etiology , Intestinal Perforation/physiopathology , Male , Patient Care Management/methods , Pneumoperitoneum/diagnostic imaging , Pneumoperitoneum/etiology , Respiratory Distress Syndrome/etiology , Shock/etiology , Tomography, X-Ray Computed/methods , Zollinger-Ellison Syndrome/etiology , Zollinger-Ellison Syndrome/physiopathologyABSTRACT
Trekkers going to high altitude can suffer from several ailments both during and after their treks. Gastro-intestinal symptoms including nausea, vomiting, and abdominal pain are common in high altitude areas of Nepal due to acute mountain sickness or due to a gastro-intestinal illness. Occasionally, complications of common conditions manifest at high altitude and delay in diagnosis could be catastrophic for the patient presenting with these symptoms. We present two rare cases of duodenal and gastric perforations in trekkers who were evacuated from the Everest trekking region. Both of them had to undergo emergency laparotomy and repair of the perforation using modified Graham's patch in the first case and distal gastrectomy that included the perforated site, followed by two-layer end-to-side gastrojejunostomy and two-layer side-to-side jejunostomy in the second case. Perforation peritonitis at high-altitude, though rare, can be life threatening. Timely evacuation from high altitude, proper diagnosis and prompt treatment are essential for taking care of such patients. Keywords: duodenal ulcer; Everest; hypoxia; mountaineering; trekking.
Subject(s)
Abdomen, Acute , Altitude , Duodenum , Gastrectomy/methods , Intestinal Perforation , Mountaineering , Stomach Rupture , Abdomen, Acute/diagnosis , Abdomen, Acute/etiology , Aged , Diagnosis, Differential , Duodenum/diagnostic imaging , Duodenum/surgery , Gastric Bypass/methods , Humans , Intestinal Perforation/diagnosis , Intestinal Perforation/physiopathology , Intestinal Perforation/surgery , Laparotomy/methods , Male , Middle Aged , Nepal , Stomach Rupture/diagnostic imaging , Stomach Rupture/physiopathology , Stomach Rupture/surgery , Treatment OutcomeSubject(s)
Colon , Digestive System Surgical Procedures , Intestinal Obstruction/surgery , Intestinal Perforation/surgery , Nutrition Assessment , Rectum , Surgical Wound Infection/epidemiology , Digestive System Surgical Procedures/methods , Emergencies , Forecasting , Humans , Intestinal Obstruction/immunology , Intestinal Obstruction/physiopathology , Intestinal Perforation/immunology , Intestinal Perforation/physiopathology , Preoperative Period , Prognosis , Retrospective Studies , Risk Factors , StentsABSTRACT
INTRODUCTION: Necrotizing enterocolitis (NEC) is a devastating disease of infancy. Full-thickness bowel wall necrosis may lead to perforation, peritonitis, and death. Timeous clinical diagnosis of impending perforation is imperative. OBJECTIVE: The objective of this study was to determine whether a persistent tachycardia in an infant with proven NEC is indicative of full-thickness bowel wall necrosis and therefore impending perforation. STUDY DESIGN: This study was conducted at the University of Pretoria academic hospitals. Forty-five neonates with proven NEC were divided into a surgical group (32 progressed to full-thickness bowel necrosis) and a nonsurgical group (13 resolved on conservative treatment). Differences in the pulse rate between the groups were analyzed. RESULTS: The 24-hour leading average pulse rate data for the surgical group were analyzed over a period of 10 days leading up to surgery and compared with the nonsurgical group. A clear upward trend of the mean pulse rate was observed in the surgical group, 48 hours prior to surgery. This was statistically significant (p < 0.05). CONCLUSION: This study demonstrated that a persistent tachycardia in a neonate with NEC is a predictor of progression to full-thickness bowel wall necrosis. Pulse rate is therefore an important clinical tool when deciding on operative management in NEC.
Subject(s)
Enterocolitis, Necrotizing/physiopathology , Heart Rate , Intestinal Perforation/physiopathology , Tachycardia/diagnosis , Disease Progression , Enterocolitis, Necrotizing/complications , Enterocolitis, Necrotizing/surgery , Female , Humans , Infant, Newborn , Intestinal Perforation/complications , Intestinal Perforation/surgery , Male , Predictive Value of Tests , Retrospective Studies , Tachycardia/etiologySubject(s)
Digestive System Surgical Procedures/methods , Diverticular Diseases/complications , Intestinal Perforation , Intestine, Small/surgery , Laparoscopy/methods , Peritonitis , Aged , Diverticular Diseases/diagnosis , Diverticular Diseases/physiopathology , Female , Humans , Intestinal Perforation/diagnosis , Intestinal Perforation/etiology , Intestinal Perforation/physiopathology , Intestinal Perforation/surgery , Intestine, Small/pathology , Peritonitis/diagnosis , Peritonitis/etiology , Peritonitis/surgery , Treatment OutcomeABSTRACT
Haemorrhoidal artery ligation has now been established as a treatment modality for symptomatic haemorrhoids. We report a case of a fit 44-year-old male who underwent the procedure as a day case, who subsequently developed pelvic sepsis due to rectal perforation. This case is the first report of a potentially life-threatening complication resulting from this procedure, which has a previously excellent safety profile.
Subject(s)
Anal Canal/surgery , Hemorrhoids/surgery , Intestinal Perforation , Ligation/adverse effects , Postoperative Complications , Adult , Humans , Intestinal Perforation/diagnostic imaging , Intestinal Perforation/physiopathology , Intestinal Perforation/therapy , Male , Postoperative Complications/diagnostic imaging , Postoperative Complications/physiopathology , Postoperative Complications/therapyABSTRACT
No disponible
Subject(s)
Humans , Male , Middle Aged , Intestinal Perforation/complications , Intestinal Perforation/physiopathology , Intestinal Perforation , Diverticulum/complications , Diverticulum/diagnosis , Ehlers-Danlos Syndrome/complications , Ehlers-Danlos Syndrome , Duodenal Diseases/complications , Duodenum/pathology , Duodenum , Magnetic Resonance Imaging , Tomography, Emission-Computed/methods , Joint Instability/complications , Joint Instability/diagnosisABSTRACT
OBJECTIVE: To identify the fetal and neonatal imaging characteristics of meconium peritonitis (MP) and their clinical outcome. We also studied the role of prenatal ultrasound (US) in antenatal diagnosis and its use in predicting the need for surgical intervention postnatally. MATERIAL AND METHODS: We conducted a retrospective analysis of a cohort of 18 infants with MP from April 2004 to March 2014. RESULTS: Prenatal US detected MP-related abnormalities in 15/18 (83.3%) fetuses. The median gestational age at initial diagnosis of MP was 24 weeks (range 19-31). Fetal ascites (93.3%) was the most common prenatal US finding. Of the 18 infants, 12 (66.7%) required surgical intervention. The overall survival rate was 94.4%. All infants with a prenatal US scan showing meconium pseudocyst or bowel dilatation required surgical intervention postnatally. DISCUSSION: A combination of ascites, intraperitoneal calcification, and echogenic bowel on fetal US raises a high suspicion of MP. Surgical intervention is indicated in the presence of meconium pseudocyst on fetal or postnatal US scan. Antenatal US has high specificity (100%) but low sensitivity (22.2%) in detecting meconium pseudocyst. A favorable outcome can be expected with early antenatal diagnosis and timely surgical intervention in a tertiary hospital.