Microbiological analysis and predictors of gallbladder infection with antimicrobial susceptibility patterns in an HIV setting.

Background South Africa has a high prevalence of people living with human immunodeficiency virus (HIV; PLWH) who have shown to affect the prevalence and severity of infection and sepsis particularly gallbladder disease.  Empirical Antimicrobial (EA) therapy for acute cholecystitis (AC) is based largely on bacteria colonisation of bile (bacteriobilia) and antimicrobial susceptibility patterns (antibiograms) obtained from the developed world where the prevalence of PLWH is very low. In an ever-emerging era of increasing antimicrobial resistance, monitoring and updating local antibiograms is underscored.  Objective Due to the paucity of data available locally to guide treatment we found it pertinent to examine gallbladder bile for bacteriobilia and antibiograms in a setting with a high prevalence of PLWH to determine if this may demand a review of our local antimicrobial policies for gallbladder infections for both EA and pre-operative antimicrobial prophylaxis (PAP) for laparoscopic cholecystectomies (LC). Methodology A retrospective observational descriptive study was undertaken at King Edward VIII Hospital, Durban, KwaZulu-Natal, South Africa. Hospital records were reviewed for all patients undergoing cholecystectomy over a 3-year period. Gallbladder bacteriobilia and antibiograms were assessed and compared between PLWH and HIV uninfected (HIV-U). Pre-operative age, ERCP, PCT, CRP and NLR were used as predictors for bacteriobilia. Statistical analyses were performed using R Project and p values of less than 0.05 were considered as statistically significant. Results There were no differences in bacteriobilia or antibiograms between PLWH and HIV-U. There was >30% resistance to amoxicillin/clavulanate and cephalosporins. Aminoglycoside-based therapy, had good susceptibility patterns whilst carbapenem-based therapy demonstrated the lowest resistance levels. ERCP and age were predictors of bacteriobilia (p<0.001 and 0.002 respectively). PCT, CRP and NLR were not. Conclusion PLWH should follow the same PAP and EA recommendations as HIV-U. For EA, we recommend, a combination of amoxicillin/clavulanate with aminoglycoside-based therapy (amikacin or gentamycin) or piperacillin/tazobactam as monotherapy. Carbapenem-based therapy should be reserved for drug resistant species. For PAP, we recommend the routine use in older patients and patients with history of ERCP undergoing LC.

An audit of interval cholecystectomy for acute cholecystitis in a low resource healthcare system.

BACKGROUND: Early laparoscopic cholecystectomy (ELC) is advocated over open cholecystectomy for acute cholecystitis (AC) as it decreases hospital costs with no increase in morbidity and mortality. The applicability of ELC for AC in a resource limited setting has not been reported. This study reviewed patients with AC at a regional state hospital in South Africa to analyse presentation delays and the related surgical strategies. METHODS: Adult patients admitted to King Edward VIII Hospital with a diagnosis of AC were included in the study. The admission, operation and discharge records were used to collect data. The severity of the cholecystitis, the time taken to present to the referral facility, the time taken to present to the regional hospital, time to operation, type of operation, conversion rates and complications were evaluated. Early presentation was recorded for two different cut-off times within 72 hours or 7 days of symptom onset. RESULTS: One hundred and thirty-nine patients met the inclusion criteria. The mean age was 47 (range 19-74) years and 86% were female. Forty-nine per cent of patients presented within 7 days and of these only 4.4% presented within 72 hours. A median of 64 days from time of admission to operative intervention was noted. All patients were considered for laparoscopic cholecystectomy (LC); there was a conversion rate of 26%. No major complications were documented. CONCLUSION: Interval laparoscopic cholecystectomy appears a reliable option in under-resourced healthcare systems.

Gastric perforation following blunt abdominal trauma.

Gastric perforations following blunt abdominal trauma are rare, accounting for < 2% of all blunt abdominal injuries. Isolated blunt gastric ruptures are uncommon. They are usually associated with other solid visceral injuries. Injuries to the stomach are associated with the highest mortality of all hollow viscus injuries. Severity of the injury, timing of presentation and presentation following the last meal as well as concomitant injuries are important prognostic factors. Imaging modalities may be unreliable in making a diagnosis and thus clinical vigilance is mandatory. We present a patient with gastric perforation following blunt abdominal trauma and review the literature.

Amyand's Hernia: A Serendipitous Diagnosis.

An Amyand's hernia refers to the presence of an appendix within an inguinal hernia sac. This uncommon finding occurs in less than 1% of all right side inguinal hernias; to date, this finding has been reported in only 14 patients with left side inguinal hernias. The preoperative diagnosis of this condition is uncommon. We report the 15th case of a left side Amyand's hernia that was diagnosed preoperatively on a contrast enema study as well as the relatively more common right-sided Amyand's hernia diagnosed serendipitously at surgery.

Small Bowel Injury in Peritoneal Encapsulation following Penetrating Abdominal Trauma.

Small bowel encapsulation is a rare entity which is usually found incidentally at autopsy. We report the first case of peritoneal encapsulation encountered serendipitously at laparotomy undertaken for penetrating abdominal trauma and review the literature on peritoneal encapsulation. We also compare this phenomenon to abdominal cocoon and sclerosing encapsulating peritonitis.

Gastric trichobezoar: an enduring intrigue.

Trichobezoar is a rare condition that may pose a diagnostic challenge. Patients with this condition often have an underlying psychiatric illness, and history may not be easily forthcoming. The condition should be entertained especially in young females. Delay in diagnosis may lead to futile complications. We report a classic case of trichobezoar in terms of patient profile, presentation, and investigative findings.