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February 1993, Volume 43, Issue 2

Case Reports


Fatema Jawad  ( 7/6, Rimpa Plaza, M. A. Jinnah Road, Karachi. )

A prospective study of 210 cases subjected to early appendicectomy within 12 hours of admission for suspected acute appendicitis at the Federal Govt. Ser­vices Hospital, Islamabad is presented. The patient population comprised of 149 males and 61 females with ages between 5 and 65 years. A detailed history was first noted down and a complete physical examination carried out. Relevant laboratory investigations and x-ray ab­domen in 80 percent cases were performed. Except 5 cases all received pen- operative antibiotics. Ampicillin was used in simple cases for 5 to 7 days and a combination of cephalosporin, metronidazole and aminoglycoside in the complicated ones for 10-14 days. Pain was the principal complaint of all the patients. Nausea orvomiting and fever between 99.2°F and 100.4°F was present in most of the cases. Leucocytosis was found in 41% of the simple acute cases whereas localized ileus was found in only 10 percent of the positive cases. Appendicectomy was followed by peritoneal toilet in the complicated cases and all the wounds were primarily closed. The diagnosis at operation was simple acute appen­dicitis in 167 cases and complicated appendicitis in 28 with 15 patients having a normal appendix. Of these negative cases, 8 had non-specific mesenteric lymph adenitis, 2 ruptured ovarian follicles, 1 intussusception, 1 pyelonephritis and in 3 no definite pathology could be determined. The duration of hospitalization extended from 2.5 days in normal and uncomplicate4 cases, to 12.5 days in complicated ones. One patient had a hospital stay of 35 days due to wound dehiscence and septicaemia. There were no operative complications and morbidity was seen in 20 cases only. Post-operative wound infection and paralytic ileus were encountered in 8.9 percent of the simple acute appendicitis cases. The difficult appendicectomies had 57.1 percent incidence of complications which included intra-abdominal abscesses, septicaemia, epididymitis and incisional hernia. There was no mortality.Highly sophisticated investigations are being used to investigate acute abdomens. These involve high finances. But none have shown 100 percent sensitivity or specificity. The diagnosis of acute appendicitis still remains clinical. The diagnostic accuracy in the presented series was 92.8 percent. Early appendicectomy is the treatment of choice for acute appendicitis. This prevents morbidity and com­plications.
To arrive at a conclusive diagnosis of a liver pathology, a tissue examination is mandatory.Wide bore needles, Menghinis and Vim Silverman have been used for the purpose. A relatively less invasive technique is the percutaneous fine needle aspiration biopsy which provides cytologic smears and tissue for microbiopsy. The cytopathology section of the Aga Khan Univer­sity Hospital, Karachi signed out FNAB cytology of the liver from 236 patients in the period January, 1985 to December, 1989. Hepatic pathology was determined by ultrasound or CT studies and most of the biopsies were conducted under ultrasound guidance. The liver aspirate was obtained using a 22 gauge spinal needle and a disposable syringe. The material obtained was put on 2 slides and spray fixed and the syringe with 1 ml alcohol and the slides were sent for cytology. The tissue remanants in the syringe were fixed in formalin and embedded in paraffin and stained with haemotoxylin and eosin. The slides were also stained with these two and papanicolaou stain. The cytopathology report gave the presence, ab­sence or suspicion of malignancy. An inadequate specimen was reported immediately by examining the cell FNAB and the procedure was reported in the same sitting. The cytological examination reported 88 benign lesions, 109 definite malignancy and 22 suspected malignancy. Abscess was found in 20 specimens of the benign group and metastatic adenocarcinoma had the highest incidence in the malignant series. 16 of the 22 suspicious smears proved to be either a primary or metastatic malignant tumour in the block preparation. The validity of cytological diagnosis was assessed in 122 cases where FNAB cell blocks were available. The sensitivity was 100% in positive cases and 84% in the negative ones. The specificity was 96% and 100% respec­tively. The percutaneous fine needle aspiration biopsy (FNAB) is a reliable and economic method to diagnose liver pathology. The procedure is safe and without significant complications. The sensitivity and specificity are comparable to results reported from other centres in the world. It is cost effective and very useful in diagnosing liver pathology especially in developing countries.
CHRONIC INVERSION OF UTERUS. Begum, N., Falsal, S.J. Ayub Med. Coil., 199 1;4:49-50.
The case of a chronic inversion of the uterus in a 28 year old woman is reported. She presented with irregular bleeding per vagina since 3 months. She had a normal home delivery a year back after which she had amenor­rhoea for 9 months followed by heavy irregular bleeding. There was a past history of 3 uneventful home deliveries conducted by a traditional birth attendant except for a short span of unconsciousness after the last childbirth. The physical examination was non-contributory. On vaginal examination a fine, smooth, mobile, non-tender mass emerging from the vault of the vagina was felt. The cervical rim could not be palpated and the uterus could not be distinguished. The speculum examination revealed the mass which bled on touch and appeared to be a fibroid polyp. The patient was examined under general anaes­thesia in the lithotomy position which confirmed the diagnosis of chronic inversion of the uterus of the third degree. Laparotomy was performed and it was noted that the uterine body was inverted alongwith both fallopian tubes, round ligament and ovarian ligaments. The inver­sion was corrected after incising the posterior cervical ring. The post-operative recovery was uneventful. Chronic inversion of the uterus is a sequelae of acute uterine inversion after a mismanaged delivery. The presented case was missed because she did not go into shock and later did not menstruate for 9 months. She attended the hospital when she developed symptoms of polymenorrhea and menorrhagia. Magnetic resonance of the pelvis gives a more accurate diagnosis of uterine inversion than the ultrasound scan.
USE OF PROPHYLACTIC ANTIBIOTICS IN CLEAN SPINAL SURGERY: A PROSPECTIVE RANDOMIZED DOUBLE BLIND SURGERY. Zaman, K., Bhatti, S.N., Yousaf, R.M., Qazi, S., Siddiq, 3. 3. Pak.Instit. Med. Sci., 199 1;2:109-111.
A prospective randomized double blind study to assess benefits of the use of prophylactic antibiotic in 100 consecutive patients undergoing clean spinal surgery, in the department of Neurosurgery, Pakistan Institute of Medical Sciences, Islamabad, is presented. There were 59 males and 41 females with ages between 18 and 71 years. Two had surgery on the cervical region, 3 on the dorsal spine, 2 on lumbar spine, 13 had fenesteration procedures and 80 patients had decomprcssive laminec. tomy. Two groups A and B were allocated by the hatdraw technique. Group A received pen-operative antibiotics as 1 gin velosef intravenously and 80 mg gentamicin locally in the wound. No post-operative antibiotics were ad­ministered. Group B received velosef and gentamycin for 5 days in addition to the pen-operative dose. Patients were examined for wound infection in the immediate post- operative period and then followed up for one month and three months. There was no evidence of immediate post-operative infection and only one patient had a sub-cutaneous stitch inflammation which responded to local treatment. Fifty-six patients had a rise in temperature between 99 and 101°F. Of these 35 had required temporary catheterization and 29 had congested throats due to intubation. Clean surgery procedures do not produce a break in the sterile technique and there is no entry in the genito-urinary or respiratory tracts. There is no risk of infection unless the surgical technique is poor. An­tibiotics are thus not indicated and their use is controver­sial. Various studies quoted in literature prove that there is no advantage of the prophylactic antibiotic being continued post-operative. Antibiotics are not a substitute to meticulous asepsis and skillful surgical technique. Less trauma or fluid collection guarantees alowinfection rate. Also short courses of antibiotics have adverse effects on the function of the RE. system. Cost of the antibiotic should also be taken into account. Review of literature proves that one dose of a broad spectrum cephalosporin at induction is sufficient for complete prophylaxis in clean surgery.

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