Assessment of efficiency of mirror therapy in preventing phantom limb pain in patients undergoing below-knee amputation surgery-a randomized clinical trial.

PURPOSE AND OBJECTIVES: Phantom limb pain (PLP) is a major cause of physical limitation and disability accounting for about 85% of amputated patients. Mirror therapy is used as a therapeutic modality for patients with phantom limb pain. Primary objective was to study the incidence of PLP at 6 months following below-knee amputation between the mirror therapy group and control group. METHODS: Patients posted for below-knee amputation surgery were randomized into two groups. Patients allocated to group M received mirror therapy in post-operative period. Two sessions of therapy were given per day for 7 days and each session lasted for 20 min. Patients who developed pain from the missing portion of the amputated limb were considered to have PLP. All patients were followed up for six months and the time of occurrence of PLP and intensity of the pain were recorded among other demographic factors. RESULTS: A total of 120 patients completed the study after recruitment. The demographic parameters were comparable between the two groups. Overall incidence of phantom limb pain was significantly higher in the control group (Group C) when compared to the mirror therapy (Group M) group [Group M = 7 (11.7%) vs Group C = 17 (28.3%); p = 0.022]. Intensity of PLP measured on the Numerical Rating Scale (NRS) was significantly lower at 3 months in Group M compared to Group C among patients who developed PLP [NRS - median (Inter quartile range): Group M 5 (4,5) vs Group C 6 (5,6); p 0.001]. CONCLUSION: Mirror therapy reduced the incidence of phantom limb pain when administered pre-emptively in patients undergoing amputation surgeries. The severity of the pain was also found to be lower at 3 months in patients who received pre-emptive mirror therapy. TRIAL REGISTRATION: This prospective study was registered in the clinical trial registry of India. TRIAL REGISTRATION NUMBER: CTRI/2020/07/026488.

Predictive models for fentanyl dose requirement and postoperative pain using clinical and genetic factors in patients undergoing major breast surgery.

ABSTRACT: Fentanyl exhibits interindividual variability in its dose requirement due to various nongenetic and genetic factors such as single nucleotide polymorphisms (SNPs). This study aims to develop and cross-validate robust predictive models for postoperative fentanyl analgesic requirement and other related outcomes in patients undergoing major breast surgery. Data regarding genotypes of 10 candidate SNPs, cold pain test (CPT) scores, pupillary response to fentanyl (PRF), and other common clinical characteristics were recorded from 257 patients undergoing major breast surgery. Predictive models for 24-hour fentanyl requirement, 24-hour pain scores, and time for first analgesic (TFA) in the postoperative period were developed using 4 different algorithms: generalised linear regression model, linear support vector machine learning (SVM-Linear), random forest (RF), and Bayesian regularised neural network. The variant genotype of OPRM1 (rs1799971) and higher CPT scores were associated with higher 24-hour postoperative fentanyl consumption, whereas higher PRF and history of hypertension were associated with lower fentanyl requirement. The variant allele of COMT (rs4680) and higher CPT scores were associated with 24-hour postoperative pain scores. The variant genotype of CTSG (rs2070697), higher intraoperative fentanyl use, and higher CPT scores were associated with significantly lower TFA. The predictive models for 24-hour postoperative fentanyl requirement, pain scores, and TFA had R-squared values of 0.313 (SVM-Linear), 0.434 (SVM-Linear), and 0.532 (RF), respectively. We have developed and cross-validated predictive models for 24-hour postoperative fentanyl requirement, 24-hour postoperative pain scores, and TFA with satisfactory performance characteristics and incorporated them in a novel web application.

Impact of Genetic Variants on Postoperative Pain and Fentanyl Dose Requirement in Patients Undergoing Major Breast Surgery: A Candidate Gene Association Study.

BACKGROUND: Postoperative analgesia is crucial for the early and effective recovery of patients undergoing surgery. Although postoperative multimodal analgesia is widely practiced, opioids such as fentanyl are still one of the best analgesics. The analgesic response of fentanyl varies widely among individuals, probably due to genetic and nongenetic factors. Among genetic factors, single nucleotide polymorphisms (SNPs) may influence its analgesic response by altering the structure or function of genes involved in nociceptive, fentanyl pharmacodynamic, and pharmacokinetic pathways. Thus, it is necessary to comprehensively ascertain if the SNPs present in the aforementioned pathways are associated with interindividual differences in fentanyl requirement. In this study, we evaluated the association between 10 candidate SNPs in 9 genes and 24-hour postoperative fentanyl dose (primary outcome) and also with postoperative pain scores and time for first analgesia (secondary outcomes). METHODS: A total of 257 South Indian women, aged 18-70 years, with American Society of Anesthesiologists (ASA) physical status I-III, undergoing major breast surgery under general anesthesia, were included in the study. Patients were genotyped for candidate SNPs using real-time polymerase chain reaction. All patients received a standardized intravenous fentanyl infusion through a patient-controlled analgesic (PCA) pump, and the 24-hour postoperative fentanyl dose requirement was measured using PCA. RESULTS: The median 24-hour postoperative fentanyl requirement was higher in rs1799971 carriers (G/G versus A/A + A/G-620 µg [500-700] vs 460 µg [400-580]) with a geometric mean (GM) ratio of 1.91 (95% confidence interval [CI], 1.071-1.327). The median 24-hour pain scores were higher in rs4680 carriers (A/G + A/A versus G/G-34 [30-38] vs 31 [30-38]) with a GM ratio of 1.059 (95% CI, 1.018-1.101) and were lower in rs1045642 carriers (A/A + A/G versus G/G-34 [30-38] vs 30 [30-34]) with a GM ratio of 0.936 (95% CI, 0.889-0.987). The median time for first analgesic was lower in rs734784 carriers [C/C versus T/T + C/T-240 minutes (180-270) vs 240 minutes (210-270)] with a GM ratio of 0.902 (95% CI, 0.837-0.972). Five of 9 clinical factors, namely, history of diabetes, hypertension, hypothyroidism, anesthesia duration, and intraoperative fentanyl requirement were associated with different outcomes individually ( P < .05) and were used to adjust the respective associations. CONCLUSIONS: The SNP opioid receptor mu-1 ( OPRM1 ) (rs1799971) was associated with higher postoperative fentanyl requirement in South Indian patients undergoing major breast surgery. Twenty-four hour postoperative pain scores were higher in catechol-O-methyl transferase ( COMT ) (rs4680) carriers and lower in ATP binding cassette subfamily B member 1 ( ABCB1 ) (rs1045642) carriers, whereas time for first analgesic was lower in potassium channel subunit 1 ( KCNS1 ) (rs734784) carriers. However, these exploratory findings must be confirmed in a larger study.

Acute Pancreatitis as the Index Manifestation of Parathyroid Adenoma.

Acute pancreatitis is one of the most common clinical emergencies encountered in our day-to-day practice. Although gallstones are the most common cause worldwide, alcohol consumption remains the leading cause of acute pancreatitis in the Indian population. We report a rare case of parathyroid adenoma, which presented with acute pancreatitis as its initial manifestation in an elderly patient. A 65-year-old gentleman with acute abdominal pain, distension, and obstipation, underwent emergency laparotomy in view of acute intestinal obstruction and was found to have acute pancreatitis intra-operatively. On post-operative evaluation, his serum calcium was >14 mg/dl and serum parathormone (PTH) was >2,000 pg/ml. Single-photon emission computed tomography (SPECT) and technetium (Tc-99m) sestamibi scintigraphy revealed a right inferior parathyroid adenoma, which was surgically excised, following which the patient made an uneventful recovery. Hypercalcemia induced by hyperparathyroidism causes auto-activation of pancreatic enzymes within the pancreatic parenchyma and is also believed to cause pancreatic duct obstruction by calcium deposition, thus causing pancreatitis. Radionucleotide scan, in addition to contrast-enhanced computed tomography, can help in localizing the lesion causing hyperparathyroidism. Appropriate resuscitation and stabilization with anti-hypercalcemic measures, including hydration and forced calciuresis, followed by surgery form the mainstay of treatment in patients with primary hyperparathyroidism. Patients with acute pancreatitis without a history of gallstone disease or alcohol intake should be evaluated for other rare causes. Early diagnosis and prompt treatment of the underlying condition can prevent the recurrence of pancreatitis.

Effect of Peri-Operative Hyperoxygenation on Surgical Site Infection in Patients Undergoing Emergency Abdominal Surgery: A Randomized Controlled Trial.

Background: The rationale for hyperoxygenation in controlling surgical site infection (SSI) has been described in many studies yet has not been defined clearly. Some studies in colorectal surgery have reported beneficial effects, whereas studies in gynecologic surgery have reported either no effect or a deleterious effect. This study assessed the effectiveness of hyperoxygenation on the reduction of SSI in patients undergoing emergency abdominal surgery. Patients and Methods: Eligible patients were assigned randomly to two groups (study group, 80% oxygen or control group, 30% oxygen). The patients in the study group received 80% oxygen and the patients in the control group received 30% oxygen intra-operatively and for two hours after surgery. Arterial blood gas analysis was done after resuscitation, at the end of the surgery, and at two hours after extubation. All patients were assessed for SSI, post-operative nausea and vomiting, and respiratory complications. Patients were followed post-operatively for 14 days. Surgical site infection was diagnosed according to U.S. Centers for Disease Control and Infection (CDC) criteria and by aerobic wound cultures. Results: After exclusion, 85 patients in the control group and 93 patients in the study group were analyzed. There was no difference for baseline, intra-operative, and post-operative characteristics between the two groups, except for higher oxygen saturation at closure and two hours post-operatively, in the 80% group (p = 0.01). Surgical site infection occurred in 29 patients (34.11%) in 30% fraction of inspired oxygen (FIO2) group and in 19 patients (20.43%) in 80% FIO2 group (p = 0.04). The risk of SSI was 59% lower in the 80% FIO2 group (adjusted odds ratio, 0.41; 95% confidence interval [CI], 0.19-0.88 vs. the 30% FIO2 group). There were no differences in post-operative nausea and vomiting and respiratory complications between the two treatment groups. Conclusions: Administration of 80% peri-operative hyperoxygenation in emergency abdominal surgery reduces SSI and is a cost-effective method.

Radiation-induced sarcoma presenting as a gluteal abscess: a diagnostic and therapeutic challenge.

Sarcomas are a rare and fatal treatment complication following radiotherapy. Radiation-induced sarcomas (RISs) presenting as a gluteal abscess is a rarity, accounting for its varied presentation. We present a case of a middle-aged woman, post-chemo-radiation for carcinoma cervix 5 years ago, who presented with gluteal abscess. Achieving haemostasis post incision and drainage under anaesthesia was a challenge. On further evaluation, she was diagnosed with radiation-induced gluteal soft tissue sarcoma. Haemostasis was achieved after radiation following failed attempts of surgical and radiological interventions. She is currently planned for chemotherapy. Cancer survivors have an increased risk of developing a second malignancy following radiation treatment. RISs are highly aggressive, exhibit a varied clinical presentation and pose a challenge in early diagnosis; thus, have a poor outcome. RISs pose a diagnostic challenge; any dubious lesion in the previously irradiated field should raise suspicion and prompt aggressive management.

Traumatic Acute Colonic Intramural Hematoma: A Rare Entity and Successful Expectant Approach.

Acute intramural hematoma in colon is a rare presentation following trauma. There are reports in literature of acute colonic hematoma following trauma, warfarin intake and in patient with coagulation disorders. In traumatic acute colonic intramural hematoma, most of the reported cases were managed surgically. Very few cases were successfully managed conservatively. We present a case of 28-year-old male who presented to the surgical emergency after two days of road traffic accident. After relevant investigations, he was found to have intramural hematoma of ascending colon, which was managed conservatively.

Carcinoma of the Accessory Axillary Breast: A Diagnostic Dilemma and a Management Challenge.

Carcinoma of the accessory axillary breast is uncommon, with an incidence of 0.2 to 0.6%. We report a patient whose biopsy of a suspicious lesion in the axilla present for one year revealed invasive ductal carcinoma (IDC). There was presence of breast tissue and absence of lymphoid tissue in the biopsy, suggesting a breast malignancy. Magnetic resonance mammography was suggestive of the lesion well away from the normal breast, confirming an accessory axillary breast. She was offered wide local excision of the lesion with axillary lymph node dissection and modified radical mastectomy (MRM), and she chose the latter. Her post-operative biopsy showed the involvement of all the 25 lymph nodes harvested. Any suspicious lesion in the axilla should be promptly worked up for malignancy. Accessory axillary breast carcinoma, if confirmed, can be addressed with wide local excision along with axillary lymph node dissection. However, further studies should clarify this and the outcomes.

Portal Annular Pancreas: Case Report of a Rare Anomaly.

Portal annular pancreas is a rare congenital anomaly in which the portal vein and/or the splenoportal confluence are completely encircled by aberrant pancreatic parenchyma. It is an asymptomatic condition and is usually an incidental finding. It is, however, important to a surgeon because the postoperative pancreatic fistula (POPF) rates following pancreatic resection are higher in patients with this anomaly. A 47-year-old male presented with features of obstructive jaundice. He was diagnosed to have periampullary carcinoma, and pancreatoduodenectomy was planned. During surgery, uncinate process was seen extending posterior to the portal vein and was communicating with the body of pancreas to the left of the portal vein. After transection, there were two pancreatic stumps. The pancreatic duct was identified in the stump anterior to the portal vein. No duct was present in the posterior pancreatic stump. We closed the posterior pancreatic stump with interrupted polypropylene sutures and performed a duct to mucosa pancreaticojejunostomy in the anterior stump. On reviewing the preoperative computed tomography (CT) scan, we were able to identify the pancreatic tissue encasing the portal vein superior to the splenic vein. Circumportal pancreas is classified based on the orientation of pancreatic duct to the portal vein and the relationship of the aberrant pancreatic tissue with the splenoportal confluence. Following pancreatoduodenectomy, the surgeon has to manage two pancreatic stumps, one anterior and the other posterior to the portal vein. No standardised technique has been described for management of the pancreatic stumps. Every surgeon planning pancreatic surgery should be aware of this rare anomaly, and look for the same in the preoperative CT scan so that appropriate plan can be made regarding the type of pancreatic anastomosis.

Aggressive Angiomyxoma in Males.

Paratesticular aggressive angiomyxoma is a very rare tumour in males. Most of documented cases of aggressive angiomyxomas have been seen in genital, perineal and pelvic regions in women of child bearing age. We report two cases of aggressive angiomyxomas in males who presented with inguinal swellings. A globular mass with greyish white, glistening cut surface was received after excision of the mass. Microscopic examination revealed a paucicellular tumour comprising of spindle shaped cells along with vessels of varying calibre. The accompanying stroma was myxocollagenous. In addition there was evidence of fat infiltration in one of the cases. Immunohistochemical staining showed CD34, desmin, vimetin positivity and negative staining for S100, actin, Estrogen Receptors (ER) and Progesterone Receptors (PR). The microscopic and immunohistochemical features favoured the diagnosis of aggressive angiomyxoma. This report of angiomyxoma in two cases of males assumes great significance in view of the extreme rarity of the tumour in males and its locally infiltrative nature.

Effectiveness of continuous wound infusion of local anesthetics after abdominal surgeries.

BACKGROUND: To assess the effectiveness of continuous preperitoneal wound infusion of local anesthetic drug bupivacaine in providing pain relief, reducing opioid consumption, and enhancing postoperative recovery. METHODS: Eligible patients were randomly allocated to two groups (study group: bupivacaine and control group: normal saline). There were 47 patients in each group. The patients received continuous infusion of either 0.25% bupivacaine or 0.9% normal saline at 6 mL/h, for 48 h, based on their group allocation, through a multiholed wound infiltration catheter placed preperitoneally. All patients also received intravenous morphine through patient-controlled analgesia pump. Pain scores at rest and on cough, morphine consumption, and peak expiratory flow rate were assessed at 12, 24, and 48 h postoperatively. The time to first perception of bowel sounds and first passage of flatus was noted. All patients were assessed for postoperative nausea and vomiting and any local or systemic complications. Chi-square test was used to compare categorical variables. The morphine consumption was compared using Student t-test, the visual analogue scale (VAS) scores were compared using repeated-measures analysis of variance. RESULTS: The mean total morphine consumption in the study group was significantly lower than the control group (18.8 ± 2.21 versus 30.8 ± 2.58 mg, P = 0.001). The median VAS scores were significantly lower in the study group than those in the control group both at rest (3 [1-4] versus 4 [2-5], P = 0.04) and during cough (4 [3-6] versus 6 [4-6] P = 0.03), except at 48 h, when the median VAS score at rest was similar (3 [1-4] versus 3 [2-4], P = 0.56). Bowel function returned earlier in study group (67.34 ± 2.61 versus 76.34 ± 5.29 h, P = 0.03). Postoperative nausea and vomiting was less in study group. Respiratory function, assessed by peak expiratory flow rate, was better in the study group (192.55 ± 12.93 versus 165.31 ± 9.32 mL, P = 0.03). The incidence of surgical site infection was similar in both the groups (3/47 versus 5/47, P = 0.06). There was no systemic toxicity of local anesthetic. CONCLUSION: Continuous preperitoneal wound infusion of local anesthetic provides effective analgesia, reduces morphine consumption and its associated side effects, and enhances the postoperative recovery by reducing the incidence of prolonged postoperative ileus.

Retroperitoneal Necrotizing Fasciitis Masquerading as Perianal Abscess - Rare and Perilous.

Necrotizing fasciitis is one of the uncommon presentations of a rapidly spreading subcutaneous tissue infection. Although the actual cause is unclear in many cases, most of them are due to the rapid proliferation of microorganisms. Retroperitoneal necrotizing fasciitis is extremely rare. It is a potentially lethal infection that requires immediate and aggressive surgical care. Early diagnosis is the key to a better prognosis. The possibility of retroperitoneal necrotizing fasciitis should be suspected in patients with symptoms of sepsis that are disproportionate to clinical findings. The rapid deterioration of the patient also gives a clue towards the diagnosis. We report a 35-year-old male with perianal abscess who had been progressed to retroperitoneal necrotizing fasciitis. The patient was managed successfully with aggressive debridement and drainage after laparotomy. Appropriate antibiotics were used to combat the sepsis. The patient recovered well at follow up, three months after discharge. Another patient, a 45-year-old male with a retroperitoneal abscess, progressed to retroperitoneal necrotizing fasciitis, and extra peritoneal drainage and debridement was done. Antibiotics depending upon the culture and sensitivity were used to control sepsis. But the patient succumbed to death 45 days after surgery due to uncontrolled sepsis. Necrotizing fasciitis of any anatomical site needs aggressive surgical care with early intervention. But retroperitoneal necrotizing fasciitis needs an extra effort for diagnosis. After diagnosis, it needs timely surgical intervention and appropriate antibiotic therapy for the recovery of the patients.

Effect of intravenous lignocaine on perioperative stress response and post-surgical ileus in elective open abdominal surgeries: a double-blind randomized controlled trial.

BACKGROUND: Perioperative stress response can be detrimental if excessive and prolonged. Intravenous (i.v.) lignocaine, while being an effective analgesic, has the added benefit of anti-inflammatory activity. This study was done to assess the effect of i.v. lignocaine on operative stress response and post-surgical ileus after elective open abdominal surgeries. METHODS: Patients (n = 134) were randomized into two groups (n = 67 each) to receive an i.v. infusion of lignocaine (group L) or saline (group S) as a bolus of 1.5 mg/kg at intubation followed by an infusion of 1.5 mg/kg/h throughout the surgery until 1 h post-surgery. Total leukocyte count (TLC), C-reactive protein (CRP) and interleukin-6 (IL-6) levels immediately and 24 h after surgery were compared with preoperative levels. Time to first passage of flatus and stools post-operatively was noted. Post-operative pain scores, analgesic requirements, and incidence of post-operative nausea and vomiting (PONV) were assessed in the two groups. RESULTS: Post-operative surge in TLC, CRP and IL-6 was attenuated in group L as compared to group S (P < 0.001, 0.018, <0.001). Time to passage of flatus and stools was earlier in group L (P = 0.04, 0.02). PONV was lesser in group L at 6 and 18 h post-surgery (<0.001, 0.28). Post-operative pain scores and post-operative morphine requirement were significantly less in group L at each point of time post-operatively (P < 0.001, <0.001). CONCLUSION: Perioperative i.v. lignocaine infusion attenuates the operative stress response, provides effective analgesia and reduces the need for opioids post-operatively. Through these effects, it reduces post-operative ileus and the incidence of PONV.

Giant inguinoscrotal hernia--report of a rare case with literature review.

Massive inguinoscrotal hernias extending below the midpoint of the inner thigh, in the standing position constitute giant inguinoscrotal hernias. We report a patient who presented with giant right inguinal hernia with bilateral hydrocele for 25 years. He had no cardiorespiratory illnesses. He was taken up for surgery under general anesthesia after preoperative respiratory exercises. Sliding hernia with entire greater omentum, small bowel, and appendix as contents was identified. Meshplasty after omentectomy with bilateral subtotal excision of sac, right orchidectomy, and scrotoplasty were done. Giant inguinoscrotal hernias pose significant problems while replacing bowel contents because of the increase in intraabdominal and intrathoracic pressures. Recurrence is another complication seen after successful surgical management. Various techniques such as preoperative pneumoperitoneum, debulking abdominal contents with extensive bowel resections, or omentectomy and phrenectomy have been tried. Postoperative elective ventilation is also needed in many cases. We describe simple reduction with omentectomy as a viable technique in this patient. He did not need elective ventilation due to preoperative respiratory exercises and preparation and review of the literature.

Carcinoma cecum presenting as right gluteal abscess through inferior lumbar triangle pathway--report of a rare case.

Gluteal abscess commonly follows intramuscular injections with contaminated needles. Carcinoma cecum is known to present with pericolic abscess due to microperforations and may rupture intraperitoneally. Gluteal abscess secondary to perforated carcinoma cecum with pericolic abscess is extremely uncommon. A 50-year-old woman who was receiving intramuscular iron injections for anemia presented with a 10×10-cm abscess in the right gluteal region and a vague mass in the right iliac fossa. After investigations, a diagnosis of perforated carcinoma cecum with pericolic abscess tracking into the right gluteal region was made, and incision and drainage were done. Fine-needle aspiration cytology from the cecal growth revealed adenocarcinoma. Unfortunately, the patient was not willing to undergo definitive treatment. This case is being reported for its rarity and as an uncommon etiology for a common condition.

Comparison of standard-pressure and low-pressure pneumoperitoneum in laparoscopic cholecystectomy: a double blinded randomized controlled study.

BACKGROUND AND OBJECTIVE: With the safety of laparoscopic cholecystectomy (LC) having been established, the current stress is on reducing the postoperative morbidity associated with this procedure. Hence, this study was undertaken to compare the effect of low-pressure (8 mm Hg) (LPLC) versus standard-pressure (12 mm Hg) (SPLC) pneumoperitoneum on postoperative pain, respiratory and liver functions, the stress response, and the intraoperative surgeon comfort in patients undergoing LC. MATERIALS AND METHODS: Patients undergoing LC (n=43) were randomized into the LPLC (8 mm Hg) group (n=22) and the SPLC (12 mm Hg) group (n=21). Postoperative pain, changes in liver function, peak expiration flow rate, C-reactive protein level, and intraoperative surgeon comfort were assessed. RESULTS: The postoperative pain scores (P=0.003, 0.000, 0.001, and 0.002 at 0, 4, 8, and 24 h), total analgesic requirement (P=0.001), and the number (total and good) of demands for analgesic in the first 24 hours (P=0.002 and 0.001) were lower in the LPLC group. The surgeon comfort in the LPLC group was significantly lesser (P=0.000). The liver function and peak expiration flow rate did not show any significant changes. C-reactive protein levels varied significantly only at 24 hours postoperatively (P=0.001). CONCLUSIONS: The use of low-pressure pneumoperitoneum (8 mm Hg) for LC is associated with a significantly lower postoperative pain. However, the use of this low-pressure pneumoperitoneum can jeopardize the surgeon's comfort.

Gossypiboma presenting as coloduodenal fistula--report of a rare case with review of literature.

The term gossypiboma is used to describe a mass of cotton matrix left behind in a body cavity intraoperatively. The most common site reported is the abdominal cavity. It can present with abscess, intestinal obstruction, malabsorption, gastrointestinal hemorrhage, and fistulas. A 37-year-old woman presented with pain in the right hypochondrium for 2 months following open cholecystectomy. As she did not improve with proton pump inhibitors, an esophagogastroduodenoscopy (EGD) was done, which showed a possible gauze piece stained with bile in the first part of the duodenum. Contrast-enhanced computed tomography (CECT) of the abdomen revealed an abnormal fistulous communication of the first part of duodenum with proximal transverse colon, with a hypodense, mottled lesion within the lumen of the proximal transverse colon plugging the fistula, suggestive of a gossypiboma. Excision of the coloduodenal fistula, primary duodenal repair, and feeding jejunostomy was done. The patient recovered well and is now tolerating normal diet. Coloduodenal fistula is usually caused by Crohn's disease, malignancy, right-sided diverticulitis, and gall stone disease. Isolated coloduodenal fistula due to gossypiboma has not been reported in the literature so far to the best of our knowledge. We report this case of coloduodenal fistula secondary to gossypiboma for its rarity and diagnostic challenge.

Solitary tubercular caecal ulcer causing massive lower gastrointestinal bleed: a formidable diagnostic challenge.

Gastrointestinal (GI) haemorrhage is a common surgical emergency accounting for approximately 1% of acute hospital admissions. Lower GI bleed is less common and less severe than upper GI bleed and is usually caused by diverticulosis, neoplasms, angiodysplasia and inflammatory bowel disease. A 51-year-old man presented with massive lower GI bleed. He had no history of tuberculosis. He underwent colonoscopy and an isolated caecal ulcer was noted. Segmental ileocaecal resection was performed and no specific cause was identifiable on histopathology. PCR was performed on this specimen and it was positive for Mycobacterium tuberculosis. This case reports the unusual presentation of tuberculosis as solitary caecal ulcer with massive lower GI bleed and highlights the role of PCR as an adjuvant diagnostic tool for its diagnosis when characteristic histopathological findings are absent.