A Case Report of Rare and Lethal Methicillin-Resistant Staphylococcus aureus (MRSA) Peritonitis in Infancy.

Peritoneal inflammation without a discernible intraperitoneal source is referred to as primary peritonitis. Only 2% of pediatric acute abdominal crises are diagnosed preoperatively. Association with other infections is uncommon and is often limited to hepatic and urinary pathogens. Here, we describe a case of primary peritonitis in a one-month-old child who had laparotomy and appendicectomy as per the recommended treatment plan. There were no accompanying hepatic and urinary diseases. In this instance, methicillin-resistant Staphylococcus aureus (MRSA) was the responsible bacteria. The use of linezolid, as per the culture sensitivity report of intraperitoneal pus, ensured a smooth recovery in this case.

Congenital Diaphragmatic Hernia With Intra Thoracic Gastric Volvulus: A Rare, Life-Threatening Combination.

Congenital diaphragmatic hernia (CDH) is a known cause of secondary gastric volvulus (GV). Both entities are life-threatening, either alone or in exceedingly rare instances when they occur in combination. Here, we describe one such rare combination of CDH and secondary GV in a nine-year-old boy, who presented to us with recurrent episodes of abdominal pain. Urgent laparotomy was done after radiological evaluation (X-ray of chest and abdomen and contrast-enhanced CT chest and abdomen), which revealed mesenterico-axial volvulus of the stomach, secondary to an underlying diaphragmatic defect in the left hemidiaphragm, thus establishing the cause (diaphragmatic defect) and effect (GV), and resulting in a favourable outcome.

Clinical, Biochemical, and Radiological Correlation in the Severity of Acute Pancreatitis: A Retrospective Study.

OBJECTIVES: To analyze the etiologies and the varying clinical presentations and to validate the clinical, biochemical, and radiological signs with severity and prognosis of acute pancreatitis. METHODS: A retrospective study of 1316 patients diagnosed with acute pancreatitis in an industrial hospital in Jamshedpur, Jharkhand, was conducted, and their clinicoradiological profiles, etiological factors, and outcomes were studied. RESULT: A total of 1316 cases were enrolled, out of which maximum cases (411 [31.23%]) were from the age group of 30-44 years, and the mean and median age were 44.54 and 47 years, respectively. A total of 731 (55.45%) patients had social habits (i.e., alcohol and smoking), and 585 (44.45%) patients did not have any social habits. Based on the etiology of acute pancreatitis (AP), the majority of cases were due to alcoholism (710 [53.95%]) followed by gallstone (343 [26.06%]) and idiopathic pancreatitis (217 [16.48%]). As per the severity of AP, most patients showed mild pancreatitis (937 [71.20%]) followed by moderate (312 [23.71%]) and severe pancreatitis (67 [05.09%]). Mild and moderate pancreatitis patients were shown in 85 and 28 cases, respectively, suggestive of chronic pancreatitis after repeated episodes of AP. But severe pancreatitis shown in 19 cases had hypocalcemia + shock + multi-organ dysfunction syndrome (MODS). In mild, moderate, and severe AP, the mortality rates were 19 (02.03%), 44 (14.10%), and 21 (31.34%), respectively. Overall, 1232 (93.62%) of AP cases recovered and were discharged in stable condition, but 84 (06.38%) cases expired. CONCLUSION: AP is a common cause of acute abdomen in patients presenting to the surgical emergency department. The management is mainly conservative with surgery limited to only a few selected cases, depending upon the severity of the disease.

Xanthogranulomatous Cholecystitis Mimicking Gall Bladder Cancer: a Diagnostic Dilemma and Review of Literature.

Xanthogranulomatous cholecystitis (XGC) is one of the rare variants of chronic cholecystitis which is characterized by inflammation of gall bladder along with infiltration by acute and chronic inflammatory cells. Intramural accumulation of lipid laden macrophages in GB wall is the hallmark of the disease. XGC results in dense adhesion of gall bladder (GB) to surrounding structures, like duodenum, colon, and stomach. The intense GB inflammation results in gall bladder perforation and development of fistulous communication between gall bladder and surrounding structures. This may also lead to formation of inflammatory mass which closely mimic gall bladder malignancy. Often differentiation from carcinoma of GB (Ca GB) on the basis of clinical presentation and even on intra-operative and radiological findings is difficult, and the issue could only be resolved on final Histopathology (HPE). We review presentation and investigation of a patient, discuss our approach in managing dilemma in treating such cases of XGC, and review the literature.

Traumatic Intramural Jejunal Hematoma: A Case Report and Review of Literature.

We report a case of a jejunal hematoma in a six-year-old boy with an antecedent history of trauma. The development of duodenal hematoma post blunt abdominal trauma is well known; however, the jejunal hematoma is very rare. A six-year-old boy was brought to Tata Main Hospital (TMH), Jamshedpur, with pain abdomen, associated with a history of trauma to the abdomen. There were no signs of peritonitis on clinical examination. Initial ultrasonology revealed mild free fluid in the abdomen. CT abdomen was suggestive of intramural hematoma in the jejunum. Exploratory laparotomy findings were in concordance with CT abdomen findings. Resection-anastomosis of the jejunum was done. The patient was discharged uneventfully on postoperative day 7. Blunt trauma to the abdomen is the principal cause of jejunal hematoma. The trauma in the majority of cases is trivial and usually the patients present late. The symptoms range from mild abdominal pain to intestinal obstruction with acute abdomen. A trial of conservative management is justifiable in a stable patient. If no clinical improvement is seen, surgical intervention is indicated. Surgical exploration was necessary because of signs and symptoms of intestinal obstruction due to jejunal hematoma. In pediatric cases, loss of functional bowel length and sudden decompensation due to expanding hematoma favor early exploration.

To Ligate or Not to Ligate? Managing the Difficult Indirect Sac in Laparoscopic Totally Extraperitoneal Repair of the Inguinal Hernia.

BACKGROUND: A laparoscopic approach to repair of inguinal hernia has become popular. The reduction of an indirect sac can be challenging especially if it is long standing or is large. In such situations, the established practice is to divide the sac at the neck and ligate it. Ligation of the sac has been shown to cause increased postoperative pain. Hence we postulated that we could possibly avoid ligation of this divided sac without causing increased intraoperative difficulty or postoperative complications. METHODS: This was a retrospective review of a prospectively maintained database of all patients who underwent laparoscopic totally extraperitoneal repair (TEP) during a 7-year period at our center with a minimum of 1 year of follow-up. We compared the outcomes of the patients who underwent only a division (group I) versus those who underwent division followed by ligation (group II) of the indirect sac. RESULTS: There were 189 and 126 patients in groups I and II, respectively. Group I patients fared better in terms of operative times and postoperative pain scores. The postoperative complication and short-term outcomes were not significantly different between the two groups. CONCLUSION: Non-ligation of a divided indirect sac during TEP is feasible and has the advantages of reduced operative times and postoperative pain and does not lead to increased complications.

Atypical presentation of gastrointestinal stromal tumor masquerading as a large duodenal cyst: A case report.

INTRODUCTION: Gastrointestinal stromal tumors (GIST) are solid tumors. A duodenal GIST masquerading as a cystic lesion has never been reported. We report a large duodenal cyst that finally turned out to be a GIST and was managed without a pancreaticoduodenectomy (PD). PRESENTATION OF CASE: A 55 year old lady presented with painful lump in epigastrium. A CT scan revealed a large exophytic cystic lesion from the duodenum with a small solid component. An endoscopy showed a polypoid lesion in the second part of the duodenum adjacent to what looked like a diverticulum. A sleeve duodenal resection, duodeno-duodenostomy and pyloric exclusion was done. The histopathology was duodenal GIST. DISCUSSION: This case posed diagnostic difficulty as it was thought to be either a duplication cyst or a diverticulum of duodenum. The odd point was the small solid component in it. We considered the possibility of a malignancy arising in these settings, which is has been occasionally reported. To our surprise, it turned out to be a GIST. An extensive literature search yielded only four reports that have reported cystic GISTS, all arising from the stomach or pancreas where they have been mistaken for pseudocysts or even a mucinous cystadenocarcinoma of the pancreas. This is the first report of a cystic GIST arising from the duodenum. CONCLUSION: GISTS can present as a predominantly cystic lesion and needs to be considered in the differential diagnosis of cystic lesions of the duodenum. Local resection is an attractive option in select cases and avoids a PD.