Acute presentation of cocoon abdomen as septic peritonitis mimicking with strangulated internal herniation: a case report.

BACKGROUND: Abdominal cocoon syndrome is a rare cause of intestinal obstruction in which loops of small bowel get entrapped inside a fibro-collagenous membrane. Condition is also known in the literature as sclerosing peritonitis and in the majority of cases, it has no known cause. Although the majority of patients exhibit long-standing signs and symptoms of partial bowel obstruction in an out-patient clinic, its acute presentation in the emergency room with features of sepsis is extremely rare. This case report aims to describe the emergency presentation of cocoon abdomen with septic peritonitis. CASE PRESENTATION: A 35-year-old male with no known co-morbidity and no prior history of prior laparotomy presented in emergency room first time with a 1-day history of generalized abdomen pain, vomiting, and absolute constipation. He was in grade III shock and had metabolic acidosis. The clinical impression was of the perforated appendix, but initial contrast-enhanced computed tomography (CECT) was suggestive of strangulated internal herniation of small bowel. Emergency laparotomy after resuscitation revealed hypoperfused, but viable loops of small bowel entrapped in the sclerosing membrane. Extensive adhesiolysis and removal of the membrane were performed and the entire bowel was straightened. Postoperatively he remained well and discharged as planned. Histopathology report confirms features of sclerosing peritonitis. DISCUSSION: Cocoon abdomen is a very rare cause of acute small bowel obstruction presenting in an emergency with features of septic peritonitis. Condition is mostly chronic and generally mimics abdominal TB in endemic areas like India and Pakistan. A high index of suspicion is required in an emergency setting and exploratory laparotomy is diagnostic and therapeutic as well and the condition mimics internal herniation in acute cases. CONCLUSION: Cocoon abdomen as a cause of septic peritonitis is extremely rare and might be an unexpected finding at laparotomy. Removal of membrane and estimation of the viability of entrapped bowel loops is the treatment of choice, which may require resection in the extreme case of gangrene.

Congenital Morgagni hernia presenting as complete small bowel obstruction in the adult - A case report.

INTRODUCTION: Congenital Diaphragmatic hernia (CDH) is a condition in which there is a defect in the diaphragm present at the time of birth. Morgagni hernia is one of the two most common types of CDH which constitutes 2%-4% of diaphragmatic hernias. They mostly remain silent or discovered as an incidental finding on radiological studies. Symptomatic adult Morgagni hernias are extremely rare. PRESENTATION OF CASE: Elderly woman presented with a 1-day history of abdominal pain, vomiting, and acute onset of respiratory distress. There was no history of trauma to the chest or abdomen. After initial resuscitation, a Chest x-ray was performed which showed bowel shadow under the right hemidiaphragm. She then underwent computed tomography (CT), which showed a defect in the right hemidiaphragm and segment of herniated small bowel loop with fecalization into the thoracic cavity. After initial resuscitation, she underwent laparotomy, reduction of bowel loops, and primary repair of the hernia defect. Postoperatively she remained well and was discharged on 4th post-operative day. DISCUSSION: Congenital diaphragmatic hernia occurs in 1 out of every 4000-5000 live births. A majority of the patients will be diagnosed either antenatally or will present with respiratory distress in the neonatal period. Presentation in adults is extremely rare and mostly characterized by abdominal pain, vomiting, intestinal obstruction with some acute respiratory distress, at the background of insignificant past medical history. Surgical management is the mainstay of treatment in symptomatic cases. CONCLUSION: CDH of Morgagni type can present uncommonly in adults with symptoms. A good history and clinical examination along with aid of chest x-ray and CT scan should establish the diagnosis. Early surgical intervention is key to prevent ischemia and later gangrene of intestinal content.

Perioperative hypothermia in colorectal surgeries: are we doing enough to prevent it?

OBJECTIVE: To determine the incidence of hypothermia in patients undergoing colorectal surgery, and to identify factors that increase vulnerability to perioperative hypothermia. METHODS: The retrospective study was conducted at the Aga Khan University Hospital, Karachi, and comprised medical records from May 2012 to June 2017 related to all patients aged >16 years of either gender who underwent colorectal procedures. Analysis about predictors of perioperative hypothermia was done using Stata 12. RESULTS: Of the 100 patients, 69(69%) were males. The overall mean age was 50.2±16.7 years. Majority cases had elective presentation 72(72%). Incidence of perioperative hypothermia was noted in 74(74%) patients. Postoperative morbidity was 16(16%), while mortality was 4(4%). Elective presentation and hypothermia before surgery were significantly associated with occurrence of intraoperative hypothermia (odds ratio: 4.5 and 1.3 respectively). CONCLUSIONS: Perioperative incidence of hypothermia was found to be quite high despite appropriate measures. Factors responsible need to be explored and rectified.

Diagnostic accuracy of CT scan in staging resectable esophageal cancer.

INTRODUCTION: CT scan is an important tool in staging of esophageal cancer. Survival can be improved by providing neoadjuvant treatment which depends on stage of esophageal cancer. So it is very important to stage the disease accurately. METHODS: The objective of this study is to determine diagnostic accuracy of CT scan to stage esophageal cancer. Ct scans of 62 patients included in the study were reviewed by a Consultant radiologist who was blinded to the final stage of tumour. Diagnostic accuracy measured by comparing with histopathological staging. RESULTS: Accuracy, sensitivity and specificity of CT for T2 and T3 are 66%, 61%, 68% and 63%, 67%, 56% respectively. Accuracy, sensitivity and specificity of CT for presence of nodal disease are 65%, 59% and 75%. CONCLUSIONS: Ct scan alone has low diagnostic accuracy for staging Esophageal Cancer.