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July 1987, Volume 37, Issue 7

Case Reports


Fatema Jawad  ( Sughra Bai Millwala Hospital, North Nazimabad, Karachi. )

TUMOUTtS OF THE DUODENAL BULB. A STUDY OF 15 CASES. Waheed, I. Pakistan Journal of Surgery, 1985; 1:29-131.
Duodenal bulb tumours in 15 patients have been presented. 1822 persons with upper gastro-in­testinal symptoms were endoscoped in the period between 1976 and 1982 in the department of surgery, Civil Hospital Karachi. A total of 15 cases from these were found to have tumours of the duodenal bulb.
The maximum number of patients were between 40 and 49 years of age. There were 11 males and 4 females. Dyspepsia, epigastric pain, vomiting especially after meals, with one case having had an episode of haematemesis, were the main symptoms. Occult blood in stool was found positive in 4 specimens, loss of weight was re­ported by one and anaemia was present in 4 cases. Barium meals were performed and reported as normal in 8 cases, an antral tumour in one case, deformed duodenal cap in 3 patients and smooth filling defects in 3 cases.
Endo scopy revealed nine sessile and six polypoid tumours. Histopathology gave a result of normal mucosa in 10 specimens. One was labelled as mild inflammation and in 4 specimens the material was insufficient. Four jntients of the 15 under went surgery although all were advised to do so. Two of these had adenomas and two turned out to be myomas.
Duodenal bulb tumours are difficult to diagnose clinically. Barium meal was also not useful in this series. Endoscopy is the only helpful method. As a polypectomy snare was not available, open excision was advised in the presented cases which was necessary as these tumours can take a malignant turn.
400 samples were collected from wounds, ear and nose secretions, urine and skin of hands, of staff in various Faisalabad hospitals. Staphylococci were isolated and transferred to nutrient agar slants after which a morphological examination and coagulase test was performed. Pure identified sam­ples of staphylococci were used for testing Penicil­lin Resistance and sensitivity by placing discs of 10 i.u. Penicillin. Penicfflinase was determined according to Lucas.
273 samples gave a positive growth of staphylococci with the maximum being from the ear secretions followed by swabs from wounds. The minimum growth was had from the hspital staffs’skin specimens. Of the total isolates 212 were pathogenic. All the urine samples proved to be positive with the nasal secretions following in number. From 212 pathogens, 200 were resistant to penicillin and of these 154 showed penicillinase production.
This very high penicillin resistance can be attributed to indiscriminate use of the drug by self medication and quackery. The study also resealed that hospital staff cafry 100 percent resistant staphylococcus aureus on their hands which proves the ignorance of the staff towards sterill­zatio n.
This undesirable drug resistance can be controlled by avoiding the indiscriminate use of antibiotics.
A preliminary study was carried out on 150 patients with uncomplicated hypertension and
85 normotensive controls to detect asyrnptomatic bacteriuria. It has been established that chronic renal infection leads to renal ischaemia which in turn causes hypertension by stimulating the renin angiotensin mechanism.
The hypertensive group comprised of 50 males and 100 females whereas the controls were made up of 32 males and 54 females. The majority of both groups were between 30-59 years of age. In the hypertensive series, 4 males and 17 females had significant bacteriuria whereas in the control group it was detected in 3 cases only. In the former group E.Coli was isolated in 16 patients, Proteus vulgaris and Kiebsiella aerogenese in 2 cases each. The controls all revealed E. Coli.
The cases with mild hypertension (100-110 mm Hg diastolic) had 21.44% bacteriuria, 10.87% of the moderate ones (111-120 mm Hg diastolic) were positive for bacteria whereas in the modera­tely severe cases (121-130 mm Hg diastolic) only 4.5% exhibited bactenuria. Of all these individuals only 20% had frank pyuria (Pus cells more than 10/HPF). All the organisms were completely sensitive to Nebcin. They showed a reduced sensi­tivity to cephalosporins and other antibiotics except to Penicillin against which they were resistant.
This hospital study went to prove that E.Coli was the predominant infecting organism in 14% of the hypertensive cases, leading to asymp­tomatic bacteriuria. The penicillin resistance can be attributed to the indiscriminate use of the drug. Long term studies wifi reveal the impact of bact.eriuria on renal function and eventually the course of hypertension.
SWALLOWED SEWING NEEDLE IN THE GAS­TROINTESTINAL TRACT. Moizuddin, Khalid, S., Khanurn, D. Pakistan Journal of Surgery, 1986; 1: 197-198.
The experience with three female patients’ having swallowed a sewing needle and presenting with upper abdominal colicky pain’ is described.
An 18 years old girl had abdominal pain of three days duration. There was a history of swallowing a needle and a plain X-ray of the abdomen showed it at the level of the first lumbar vertebra. Laparotomy revealed the needle in the pancreas after perforating the stomach. The second case was of a 46 years old lady with epigastric pain of ten weeks duration. There was no history of swallowing a needle, which was detected in the film of an oral cholecystogram to be lying at the level of the twelfth thoracic ver­tebra. Laparotomy again revealed the needle in the pancreas.
The third case, a twenty year old girl, presented with abdominal pain since four weeks. She gave a history of accidentally swallowing a needle a month earlier. Previous X-rays showed the needle to be in the left iliac fossa and later in the right iliac fossa. But subsequent films projected the needle constantly at the level between the first and second lumbar vertebrae. The patient was admitted with colicky abdominal pain and an emergency laparotomy was performed. The needle was found in the pancreas. The posterior wall of the stomach had been perforated by it, which was repaired. No other needles were found in the abdominal cavity. An uneventful recovery ensued.
Swallowing of pins, needle, buttons, coins, rings, keys and fish-hooks have been reported in literature. 80 percent of the foreign bodies pass out spontaneously without complications. Fibre optic endoscopy has revolutionized the manage­ment of foreign bodies in the upper gastro-intes­tinal tract. They can now be removed as a day care procedure. A plain X-ray abdomen is however necessary for localization. Laparotomy is essential in all cases of perforation.

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