Perforation of the gall bladder following typhoid fever-induced ileal perforation.

Gall bladder perforation is a potentially life-threatening condition. Spontaneous perforation is infrequent and rarely seen in the absence of gallstones but gall bladder perforation is an occasional complication of typhoid fever. If such perforations are not treated in time, mortality rates are very high. We report a case of gall bladder perforation complicating typhoid fever following enteric perforation of the ileum necessitating sequential laparotomies during the same admission.

A hernia in the inguinal region is not always an inguinal hernia.

A male patient of 60 years presented with a swelling in the left groin of 10 months duration. Past records showed bilateral lumbar sympathectomy and omentopexy done 20 and 6 years back, respectively, for Buerger's disease. Abdominal examination revealed a huge hernial swelling in the left groin extending from the symphysis pubis to anterior superior iliac spine measuring 25 x 18 cm. On exploration, the contents were intestines and omentum, which were coming out through a defect of 5 x 3 cm in the lower fibers of the conjoint muscle 4 cm cephalad to the deep ring, a finding which made the final diagnosis as an incisional hernia. We present this interesting case as a very rare complication of omentopexy, probably not reported previously, and an unusual case of an incisional hernia presenting as an inguinal hernia which is very difficult to diagnose unless encountered before. Its rarity and clinical challenge is highlighted.

The changing survival scenario in gangrenous sigmoid volvulus: a four-decade study.

There is a suspicion that mortality in gangrenous sigmoid volvulus has considerably declined over the recent years. This study was aimed to assess if this is a genuine trend, applicable to the patients, of this study too, and to identify factors responsible for the change, if any. Seventy-eight patients operated for gangrenous sigmoid volvulus, in the last four decades of the just gone century, were analysed. Nine clinical parameters were studied to identify factors responsible for mortality and to see if there was a change in clinical presentation in the later decades. Mortality in the 4 studied decades varied between 15.4% and 65%. Differences were significant (p<0.05) only between the decades of the seventies and eighties and between bunched pre 1980 (48%) and post 1980 (20%) decades. A sea change in survival scene occurred at the end of the decade of the seventies. The change was not accompanied by a concomitant improvement in clinical presentation (p>0.05). Two facts which could explain improved survivals in the post. 1980 period were, the increased recognition of gangrene extending beyond the area of constriction and improved survival after primary anastomoses (p<0.05). These indicated a more accurate assessment of viability and the distance between the cut bowel ends, a stricter selection of cases for primary anastomosis and using Hartmann operation in doubtful situations. Mortality in gangrenous sigmoid volvulus, without knotting in the Indian population has genuinely declined from over 50% in an earlier time to 20% in the later 20 years of the last century, the watershed in the changed scenario being the year 1980.

Study on the anatomical dimensions of the human sigmoid colon.

Although the sigmoid colon is commonly afflicted with disease, studies on its anatomical dimensions are scarce. It is suspected that dimensions of the sigmoid colon change with age. This study documents data on the anatomical measurements of the sigmoid colon in 70 Indian subjects (51 live and 19 cadavers). Seven parameters of sigmoid colon anatomy measured included length and width of the sigmoid colon and mesocolon at specific points. Three mesocolic indices (width to length ratios) were calculated. Comparisons of measurements in the live and cadaver subjects and in the two sexes were made. The relationship of change in parameters with age was assessed. Appropriate statistical methods were used and the differences were considered significant at P < or = 0.05. The study showed wide ranging variations in the values of various measured parameters of the sigmoid colon. Seven patterns of the shape of the sigmoid loop were identified. In the commonest pattern the sigmoid mesocolon was vertically longer than wide (dolichomesocolic), the sigmoid loop having its maximum convexity located just a little proximal to the apex. Patterns where the width of the mesocolon was greater than the vertical length (brachymesocolic) were also observed. The gender analysis showed that the sigmoid mesocolon of the female was brachymesocolic (wider than long), whereas that of the male was dolichomesocolic (longer than wide). This might explain the higher incidence of sigmoid volvulus in the male. This study also showed that the measurements of the sigmoid colon and its mesocolon do not change significantly within the age range of 16-60 years in the two sexes. Also noteworthy is the observation that in the cadaver the sigmoid colon shows considerable shrinkage, particularly of its mesocolon; consequently the data from cadaver subjects, though valuable for anthropometric use, have limitations when used for clinical applications.

Gangrenous sigmoid volvulus: a clinical study of 76 patients.

BACKGROUND AND AIMS: This study investigated the clinical picture of gangrenous sigmoid volvulus presented by Indian patients to describe the various patterns of gangrene and to identify the risk factors leading to the very high mortality from this disease. PATIENTS AND METHODS: A structured protocol including nine parameters was used to study risk factors in 76 patients treated at two major teaching hospitals in India. The clinical picture of patients at the two hospitals did not differ significantly. RESULTS: Contrary to expectations, we found gangrene in 26% of cases extending beyond the area of constriction into the rectum/descending colon. This extension was sometimes patchy and had an ill defined line of demarcation, which may lead to an error in judgment and cause a failure of anastomosis, which can be fatal. Risk factors were age over 60 years, the presence of shock on admission and a history of previous episodes of volvulus. CONCLUSION: This study identified three risks for survival. It is suggested that all patients with nongangrenous sigmoid volvulus undergo a recurrence-prevention procedure immediately or electively. We also found that extension of gangrene beyond the confines of the constriction is not uncommon, calling for caution on the part of the treating surgeon.

A polystyrene based membrane electrode for cadmium(II) ions.

A polystyrene based membrane of 3,4:12,13-dibenzo-2,5,11,14-tetraoxo- 1,6,10,15-tetraazacyclooctade-cane shows a Nernstian response to Cd(II) ions over a wide concentration range (3.16 x 10(-6) - 1.00 x 10(-1) mol L(-1) with a Nernstian slope of 29.8 mV/decade of concentration, between pH 2.0 and 6.0. This electrode has been found to be chemically inert and of adequate stability with a response time of 20s. The electrode gives reproducible results with a lifetime of 130 days. The membrane works satisfactorily in a partially non-aqueous medium up to a maximum 35% (v/v) content of methanol and ethanol. The practical utility of the proposed chemical sensor has been observed by using it as end-point indicator in the titration of Cd(II) ions with EDTA. The potentiometric selectivity coefficient values indicate that the membrane sensor is highly selective for Cd(II) ions over a number of cations. Small amounts of surfactants do not disturb the functioning of the sensor. This electrode has also been used to estimate cadmium ions in real samples.

Double gall bladder with two disease processes.

A double gall bladder is a rare congenital anomaly which is usually diagnosed by preoperative ultrasonography. Either one, or both lobes, of the double gall bladder, may be diseased. We report a patient in whom the two lobes were affected by different disease processes, namely, cholesterosis, and cholelithiasis with mucocele.

Nonresective alternative for the cure of nongangrenous sigmoid volvulus.

PURPOSE: Recurrence in sigmoid colon volvulus is a very vexing problem, because it occurs after all types of treatment including a resection of the sigmoid. A nonresective procedure that prevents recurrence in the long term has been devised and tried during the period 1968 to 1992. METHODS: The procedure involves extraperitonealization of the whole sigmoid colon via a left paracolic gutter incision in a manner akin to an extraperitonealized colostomy and placing it in the left half of the infraumbilical abdominal wall. This article presents a study of 84 patients who underwent this operation and who were followed-up. Some very useful practical points for ensuring the success of the procedure are also presented. RESULTS: The subjects comprised 58 male and 26 female patients, aged 10 to 81 (median, 60) years. The operating time ranged from 40 to 70 (median, 50) min. The operative mortality (9 percent) and morbidity of the procedure including cardiopulmonary complications (7 percent), incidence of small-bowel obstruction (1 percent), and incisional hernia formation (2.3 percent), were reasonably low. The incidence of wound-healing problems was significantly (P < 0.02) reduced in the 1980s and 1990s. Seventy-six patients were available for follow-up ranging from 0.5 to 25 (mean+/-standard error, 6.671+/-0.573; median, 6) years. Forty-eight patients were followed-up for five or more years. No patients developed recurrence of volvulus during the entire follow-up period. CONCLUSIONS: This nonresective, recurrence-free procedure provides a cure for nongangrenous sigmoid volvulus. It may be performed safely, even in relatively poor-risk patients, with acceptably low morbidity and mortality rates.

Phthalanilic acids as highly selective reagents for the amperometric determination of thorium(IV).

Th(IV) has been determined by amperometric titration at an applied emf of -1.0 V with ten phthalanilic acids. Of these, the 2,5-dichloro, 4-bromo, 3-nitro, 4-nitro and 1-naphthyl derivatives were found promising analytical reagents and most effective. Th(IV) in the range 11.6-1160 mg/10O ml can be determined with an error of +/- 0.3%. The possible interference of 46 ions was studied and only two. Pd(II) and Zr interfered; they could be masked by the addition of dimethylglyoxime or Nioxime, and pyrophosphate respectively.

Diphenic acid as a selective reagent for the amperometric determination of thorium(IV).

Th(IV) has been titrated amperometrically at an applied e.m.f of -1.0 V (dropping mercury electrode vs. SCE) with diphenic acid (neutralized with sodium hydroxide). Th(IV) in the range 8.0-60.0 mg/100ml can be determined with an error of +/-0.5%. A number of foreign ions including Ce(IV), Zr(IV), La(III), U(IV), U(VI) do not interfere even if present in excess but traces of Ti(IV) do. The method is rapid and selective and has been used for the determination of Th(IV) in monazite sand.

Massive necrosis and perforation of the colon in amebiasis.

A successfully treated case of acute fulminating necrotizing amebic colitis characterized by signs of toxemia, septicemia and peritonitis is reported. Early diagnosis and staged surgical procedures apparently lower the mortality. Intensive antiamebic therapy should be instituted as soon as amebiasis is confirmed, otherwise surgical therapy is likely to fail.