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Pattern of cases and its management in a general surgery unit of a rural teaching institution

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To study the pattern of general surgery cases and their management in a rural teaching institution. This descriptive case-series was conducted prospectively in Surgical Unit II at Fatima Hospital and Baqai Medical University, from June 16, 2005 to June 15, 2010. There were 1125 patients in the series who were managed either conservatively or operated upon. All patients with symptoms suggesting a surgical disease and managed as a surgical case were included, while cases that were shifted to other departments and those that left against medical advice were excluded. The majority of patients had alimentary tract diseases 327 (29.1%), followed by urinary tract diseases 241 (21.4%), hernia 176 (15.6%), superficial lumps 135 (12%), hepato-biliary-pancreatic diseases 102 (9.1%), breast diseases 47 (4.2%), scrotal diseases 37 (3.3%), thyroid diseases 19 (1.7), salivary gland diseases 10 (0.9%), vascular diseases 4 (0.4%), thoracic diseases 2 (0.2%), and miscellaneous 25 (2.2%). A total of 726 (64.5%) patients were managed as elective cases, while 399 (35.5%) were managed as emergency cases. As many as 834 (74.1%) patients were managed by operations and 244 (21.7%) patients by conservative treatment, while 47 (4.2%) patients were referred. Seven patients expired, giving a mortality rate of 0.62%. The commonest cause of seeking surgical care was alimentary tract diseases, followed by urinary tract diseases, hernias, superficial lumps, hepato-biliary-pancreatic diseases, breast diseases, scrotal diseases and thyroid diseases. Baqai Medical University is catering to the needs of rural population by providing essential surgical care to a broad spectrum of surgical diseases.

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In a 12-month prospective study 370 patients with acute abdominal pain were admitted to a single surgical unit of a large teaching hospital. The most common diagnoses were appendicitis (23.5 percent), Non-specific abdominal pain (NSAP) (21.4 percent), acute intestinal obstruction (10.8 percent), gynaecological causes (9.5 percent, and peptic ulcer (9.2 percent). Emergency operations were performed in 146 patients (39.5 percent). Appendicectomy was the commonest operation (77 cases or 52.7 percent) and there was a high incidence of complicated appendicitis (41.6 percent). Eleven patients (3.0 percent) died within 30 days of admission (8 postoperative and 3 non-operative deaths). The clinical spectrum of the acute abdomen in this study shows that surgeons in developing countries are not facing surgical challenges similar to those of their counterparts in developed countries and the most important diagnostic distinction surgeons in both localities have to make is that between acute appendicitis and non-specific abdominal pain.
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Acute appendicitis is among the most frequent causes of surgical abdominal disease worldwide. Data from the Nationwide Inpatient Sample of the Healthcare Utilization Project were used to estimate the prevalence and disease burden of appendicitis-related hospitalizations in the United States in 1997. The data are a representative sample of discharge records from community hospitals drawn from 22 states in the United States. In the United States in 1997, there were an estimated 252,682 (95% CI: 242,957-262,407) appendicitis-related hospitalizations. The mean length of stay and total charges for appendicitis-related hospitalizations were four days (95% CI: 3.4-4.6) and $11,645 (95% CI: $11,299-$11,992) per hospitalization, respectively. Appendicitis-related hospitalizations associated with post-operative infection, peritoneal abscess, or peritonitis had longer average lengths of stay and higher average costs when compared to hospitalizations associated with local appendicitis without post-operative infection. Appendicitis cases among very young and older patients were more likely to be associated with peritoneal abscess, peritonitis, or post-operative infection. In 1997, appendicitis-related hospitalizations accounted for 0.6% of all hospitalizations in the United States, resulting in approximately one million hospital days and $3 billion in hospital charges. Between 1984 and 1997, the rate of appendicitis hospitalizations in the U. S. population declined slightly, whereas the total number of hospital days remained unchanged.
Gallstone disease remains one of the most common medical problems leading to surgical intervention. Every year, approximately 500,000 cholecystectomies are performed in the US. Cholelithiasis affects approximately 10% of the adult population in the United States. It has been well demonstrated that the presence of gallstones increases with age. An estimated 20% of adults over 40 years of age and 30% of those over age 70 have biliary calculi. During the reproductive years, the female-to-male ratio is about 4:1, with the sex discrepancy narrowing in the older population to near equality. The risk factors predisposing to gallstone formation include obesity, diabetes mellitus, estrogen and pregnancy, hemolytic diseases, and cirrhosis. A study of the natural history of cholelithiasis demonstrates that approximately 35% of patients initially diagnosed with having, but not treated for, gallstones later developed complications or recurrent symptoms leading to cholecystectomy. During the last two decades, the general principles of gallstone management have not notably changed. However, methods of treatment have been dramatically altered. Today, laparoscopic cholecystectomy, laparoscopic common bile duct exploration, and endoscopic retrograde management of common bile duct (CBD) stones play important roles in the treatment of gallstones. These technological advances in the management of biliary tract disease are not infrequently accomplished by a multidisciplinary team of physicians, including surgeons trained in laparoscopic techniques, interventional gastroenterologists, and interventional radiologists. With the evolution of laparoscopic cholecystectomy, there has been a global reeducation and retraining program of surgeons. However, the treatment of choice for gallstones remains cholecystectomy. In recognition of the revolutionary advances in the treatment of cholelithiasis, it is the purpose of this collective review to describe recent information on the following topics: types of gallstones, asymptomatic gallstones, symptomatic gallstones, chronic cholecystitis, acute cholecystitis, and other complications of gallstones. Gross and compositional analysis of gallstones allows them to be classified as cholesterol, mixed, and pigment gallstones. When asymptomatic gallstones are detected during the evaluation of a patient, a prophylactic cholecystectomy is normally not indicated because of several factors. Only about 30% of patients with asymptomatic cholelithiasis will warrant surgery during their lifetime, suggesting that cholelithiasis can be a relatively benign condition in some people. However, there are certain factors that predict a more serious course in patients with asymptomatic gallstones and warrant a prophylactic cholecystectomy when they are present. These factors include patients with large (>2.5 cm) gallstones, patients with congenital hemolytic anemia or nonfunctioning gallbladders, or during bariatric surgery or colectomy. Epigastric and right upper quadrant pain occurring 30-60 minutes after meals is frequently associated with gallstone disease. The diagnosis of chronic cholecystitis is made by the presence of biliary colic with evidence of gallstones on an imaging study. Ultrasonography is the diagnostic test of choice, being 90-95% sensitive. The surgical literature suggests that 3-10% of patients undergoing cholecystectomy will have CBD stones. Intraoperative laparoscopic ultrasonography has recently replaced cholangiography as the method of choice for detecting CBD stones. Ultrasonography and radionuclide cholescintigraphy (HIDA scan) are useful in establishing a diagnosis of acute cholecystitis. Laparoscopic cholecystectomy should also be used in the treatment of acute cholecystitis. Laparoscopic cholecystectomy is more likely to be successful when performed within 3 days of the onset of symptoms. It is important to remember that gallstones can lead to a variety of other complications including choledocholithiasis, gallstone ileus, and acute gallstone pancreatitis.
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Article
Abdominal pain of less than a weeks' duration is the presenting complaint in one of every five patients admitted to the surgical Accidents and Emergency Ward of the Komfo Anokye Teaching Hospital in Kumasi. This study is a prospective one, to determine the cause of abdominal pain in a large number of patients. A monthly audit of discharge summaries for all patients admitted with acute abdominal pain was prepared and transferred to a special study pro forma to provide data over the 84-month period from January 1998 to December 2004. There were 3114 patients, 2070 men and 1044 women. The ages ranged from 15 to 95 years. The seven most common causes of the admissions were acute appendicitis 698 (22.4%), typhoid ileal perforation (506) 16.2%, acute intestinal obstruction 391 (12.6%), gastroduodenal perforations 342 (11.0%), non-specific abdominal pain 306 (9.8%), abdominal injures 260 (8.3%) and acute cholecystitis 102 (3.2%). There were 1976 (63.4%) emergency operations. Appendicectomy was a common operation that was carried out (638 cases or 32.3%). Two hundred and thirty patients (7.4%) died. Thirty-five patients died before and 195 after operation. Of these 230 deaths, 110 (47.8%) reported to the hospital after three or more days of illness. Twenty-six per cent and 23.7% of postoperative deaths occurred after emergency colonic resections and closure of gastroduodenal perforations, respectively. Acute appendicitis, typhoid ileal perforation, acute intestinal obstruction and gastroduodenal perforations were the leading causes of acute admissions for abdominal pain to our hospital. Late presentation was associated with increased mortality.
Article
Appendicitis is the most common acute surgical condition of the abdomen. Age, sex and seasonal variations have been observed in many studies. To describe and find the possible differences in the epidemiology of acute appendicitis in Shahr-e-Rey, we carried out a retrospective study of all patients with acute appendicitis admitted to Shohadaay-e Haftom-e Tir hospital as it is the only hospital in this restricted part of Tehran. Using hospital discharge abstract of patients who were admitted with the diagnosis of acute appendicitis from summer 1996 to spring 2004, we studied the demographic features, particularly age and sex, date of admission and final diagnosis of these patients. During the observation period, 1093 cases were admitted with the diagnosis of acute appendicitis. Of these, 74.4% were males and 6.1% were not actually an acute appendicitis. The age-specific incidence of acute appendicitis has different patterns in male and female. The incidence was highest in males aged 20-29 years whereas in females the highest incidence was observed in 10-19 years age group. A significant seasonal effect was also observed, with the rate of acute appendicitis higher in the summer months (p<0.006). The rate of false positive diagnosis was highest in the patients aged 0-9 years (p<0.0001). Of those correctly diagnosed, 85.5% had uncomplicated acute appendicitis; 8.3% had perforation; and others (6.2%) had acute appendicitis complicated with other situations. Appendicitis is more common in males, in those aged 20-29 years, and during the summer months. The age-specific incidence and sex ratio of acute appendicitis give the impression that epidemiologic features of acute appendicitis are different with worldwide data. However, the seasonal variation and false positive rate of acute appendicitis are in a good agreement with other studies.
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Acute pyelonephritis (APN) is a frequent and possibly severe pathological condition responsible for more than 100,000 hospitalizations per year in the United States. Etiology is prevalently Escherichia coli, and risk factors include sexual activity, genetic predisposition, old age and infection via urological instrumentation. The exact correlation between APN and vesicoureteral reflux has not yet been defined. Diagnosis of APN may be clinical, but examination using computed tomography (CT) or nuclear magnetic resonance (NMR) spectroscopy allows a more precise definition and may provide evidence of abscesses. Severe cases should be treated with a fluoroquinolone or extended-spectrum cephalosporin associated or not with aminoglycoside. Treatment should be continued for at least 10 days. Long-term evolution of APN is still unknown, even if formation of cortical scars and possible development of macroalbuminuria or renal failure are described. Pregnancy, diabetes and renal transplantation represent situations in which APN may be particularly severe. Formation of renal abscesses is underestimated and must be evaluated by CT or NMR spectroscopy evaluation. Abscesses must be drained only if they are of great size.
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Acute bacterial skin infections are very common, with various presentations and severity. This review focuses on deep skin infections. We separate acute nonnecrotizing infections of the hypodermis (erysipelas), forms with abscesses or exudates and necrotizing fasciitis. These three types actually differ in risk factors, bacteriology, treatment and prognosis. Leg erysipelas/cellulitis occurs in more than one person/1000/year. It remains mainly due to streptococci. Foot intertrigo is an important risk factor. Necrotizing fasciitis is much rarer and usually occurs in patients with chronic diseases. Staphylococci, especially community-acquired methicillin-resistant strains in some areas, play a growing role in the intermediate form of cellulitis with abscesses and exudates. For erysipelas or noncomplicated cellulitis, antibiotic treatment at home, when feasible, is much less expensive and as effective as hospital treatment. Intermediate cases with collections and exudates often require surgical drainage. For necrotizing fasciitis early surgery remains essential in order to decrease the mortality rate. Antibiotic treatment of deep skin infections must be active on streptococci; the choice of a larger spectrum of activity depends on clinical presentation, risk factors and the burden of methicillin-resistant staphylococci in the environment.
Article
Skin and soft tissue infections are common diseases. The spectrum ranges from slight furuncles to severe necrotizing soft tissue infections. Grampositive bacteria account for 70-80 % of cases as causative organisms. Diagnostics include rapid evaluation of locally limited or diffuse spreading extent of the disease. In complicated skin and soft tissue infections, surgical intervention with debridement and necronectomy is indicated. Necrotizing skin and soft tissue infections call for programmed redebridement. If systemic signs of inflammation are present (fever > 38 degrees C, leukocytosis, CRP elevation) or significant comorbidity exists, application of antibiotics is indicated. The prognosis in operatively treated patients is dependent on the time of surgical intervention.