Clin. Pract., Volume 3, Issue 1 (January 2013) – 14 articles

Hepatic encephalopathy (HE) is a common long term complication of porto-systemic shunt. We report herein the case of a 59-year-old man with Child-Pugh A cirrhosis treated successfully 9 years earlier with distal splenorenal shunt for uncontrolled variceal bleeding. In the last year, he developed a severe and persistent hepatic encephalopathy secondary to the shunt, which was resistant to medical therapy. As liver transplantation was not available and obliteration of the shunt was hazardous, we performed subtotal colectomy in order to reduce ammonia production. This therapeutic option proved successful, as the grade of encephalopathy decreased and the patient improved. Our experience indicates that colonic exclusion should be considered as an option in the management of HE refractory to medical treatment in highly selected patients when liver transplantation is not available or even as a bridge given the long waiting time on lists. Full article

Vascular leiomyosarcoma (LMS) are unique. The inferior vena cava (IVC) is the most affected organ (about 38% cases). We report the observation of a 50-year old woman who consulted for right upper quadrant pain. Imaging studies revealed a retroperitoneal mass that mimic a LMS of the IVC. The patient was operated. A resection of the IVC along with the tumor was performed without reconstruction. The management of LMS is surgical and depends upon the location and tumor characteristics. Full article

Wegener’s granulomatosis is a granulomatous vasculitis that can present with a wide spectrum of clinical manifestations. This disease entity predominantly affects the respiratory tract and the kidneys. Two forms of Wegener’s granulomatosis have been recognized: systemic and limited. It has not been established if the two forms represent separate disease entities or different stages of the same condition. In the limited form of Wegener’s granulomatosis there is no immediate threat to the function of vital organs and there is no evidence of glomerulonephritis. Environmental factors that could serve as triggers for the activation of Wegener’s granulomatosis have not been clearly defined. We report a case of a 78- year old male who was found to have bilateral pulmonary nodules on pre-operative chest X-ray and was diagnosed with the limited form of Wegener’s granulomatosis. The patient developed Clostridium difficile infection, and shortly after that active glomerulonephritis, a manifestation of systemic Wegener’s granulomatosis. Full article

Arthrography is useful method to evaluate obstruct factors and the congruity of the femoral head for developmental dysplasia of the hip. We usually use an air injection to ascertain whether the needle is accurately insert intraarticularly, because leakage of the contrast medium may make it difficult to identify intraarticular structure in the hip joint. We report the experience the case that suspected air embolism by air injection in the arthrogram. An air injection for arthrography must be avoided the case of infants. To confirm that a needle is correctly inserted intraarticularly, it is preferable to inject saline. Alternatively, it may be suitable to use sonography for confirming the position of the needle for arthrography. Full article

Management of a solitary pancreatic pseudocyst with endoscopic transpapillary stent drainage is a well recognized treatment modality. Endoscopic options are however limited in the presence of multiple pancreatic pseudocysts. Conventionally surgery has been the mainstay of treatment in this situation. In this case report, we present a patient with multiple pancreatic pseudocysts who was successfully treated via transpapillary placement of pancreatic duct stent. Full article

Primary retroperitoneal teratoma is a rare entity in adults. We present a case of 23-yearsold female who presented with complaint of abdominal pain in left upper quadrant. Computed tomography scan revealed a retroperitoneal retropancreatic teratoma near celiac axis with intra thoracic extension. Laparotomy with tumor resection was done. The case report is interesting for intra thoracic extension of retropancreatic teratoma. Full article

Despite good cover with 7-valent vaccination, invasive pneumococcal infections may still be misdiagnosed and may lead to lifethreatening situations or death in young children. New serotypes are emerging and, therefore, clinicians must keep a high level of suspicion in young children regardless of their vaccination status. We report three cases of invasive pneumococcal infection due to new serotypes not covered by the 7-valent conjugated vaccine, two of which led children to death. Full article

This study aims to compare the efficacy of antiseptic dressings, hyperbaric oxygen therapy, and recombinant human platelet derived growth factor (rhPDGF) for two reasons: i) to reduce the incidence of lower limb amputations in diabetic foot ulcer; ii) to limit the duration of stay in the hospital. A prospective randomized trial was conducted on 60 patients with stage III and IV diabetic foot ulcers (International Association of Enterostomal Therapy classification) and patients were divided randomly in three different therapy groups - antiseptics, hyperbaric oxygen therapy, recombinant platelet derived growth factor, with 20 patients in each group. Patients were managed initially on inpatient and then on outpatient basis till the ulcer healed completely. Results among three groups were compared using unpaired T test and the level of significance was set at P<0.05 using ANOVA. This study compares the efficacy of hyperbaric oxygen therapy, antiseptic dressings, and rhPDGF in grade III and IV diabetic foot ulcers. P value (0.0348) was significant for complete wound contraction while p value healing time (0.6534) and ulcer size (0.0593) in the groups was not significant. PDGF is safe, effective and easy to apply. Results are comparable with hyperbaric oxygen (HBO) therapy and cost of treatment is lower than other therapies. Diabetic foot ulcer management requires multidisciplinary and aggressive approach. PDGF should be recommended for all grade III and IV diabetic foot ulcer at least 8 weeks old. HBO is equally good an option but has limitations and side effects. Full article

The authors report a case of spontaneous transmesenteric hernia with strangulation in an adult. Transmesenteric hernia (TMH) is a rare cause of small bowel obstruction and is seldom diagnosed preoperatively, and most TMHs in adults are related to predisposing factors, such as previous surgery, abdominal trauma, and peritonitis. TMH are more likely to develop volvulus and strangulation or ischemia. A brief review of etiology, clinical features, diagnosis, and treatment is discussed. Full article

VACTERL association (OMIM 192350) is a non-random combination of multiple congenital malformations including vertebral, anal, cardiac, tracheoesophageal, renal and limb anomalies. The wide spectrum of defects suggests the occurrence of defective development during early embryogenesis. The authors report a case of a complex polymalformative association detected by ultrasound in the first trimester of pregnancy. The ensuing fetal study revealed the presence of vertebral, anorectal, renal and limb anomalies and therefore was considered a case of VACTERL association. This complex association generally entails a poor prognosis. Its early detection allows discussion of management options, including medical termination of pregnancy. Full article

Benign multicystic peritoneal mesothelioma (BMPM) is an uncommon lesion. It presents as a lump in abdomen or a finding seen on imaging modalities. Surgery is the primary modality of treatment. However, it has a high recurrence rate; this results in adhesions and subsequent surgeries difficult. We present a case of recurrent BMPM in a female operated twice earlier in a rural centre. Imaging modalities showed majority of the lesion in paracolic and retroperitoneal region. Hence, retroperitoneal approach for surgery was taken. This avoided previous surgical adhesions. A brief case report on this novel approach and review of literature is presented. Full article

Citrullinemia type I (CTLN1) is an inherited urea cycle disorder, now included in most newborn screening panels in the US and Europe. Due to argininosuccinate synthetase deficiency, CTLN1 can lead to recurrent hyperammonemic crisis that may result in permanent neurologic sequelae. Vomiting in patients with urea cycle disorders may either be the result or cause of acute hyperammonemia, particularly if due to an illness that leads to catabolism. Therefore, age-appropriate common etiologies of vomiting must be considered when evaluat- ing these patients. We present a 1-month old male infant with CTLN1 who had a 1-week history of vomiting and was discovered to have hypertrophic pyloric stenosis. This is the first documented case of an infant with CTLN1 who was later diagnosed with hypertrophic pyloric stenosis, and only the second case of concomitant disease. Full article

We describe a case of progressive syringomyelia following post-infectious trapped fourth ventricle (TFV), which resolved after shunting of the fourth ventricle. A 28-year-old female who had previously undergone treatment of intracerebral hemorrhage and meningitis developed a hydrocephalus with TFV. After 3 years she developed disturbance of walking and coordination. Cranial-CT revealed an enlargement of the shunted fourth ventricle as a result of shunt dysfunction. Furthermore a cervical syringomyelia developed. The patient underwent a revision of a failed fourth ventriculo- peritoneal shunt. Postoperatively, syringomyelia resolved within 6 months and the associated neurological deficits improved significantly. An insufficiency of cerebrospinal fluid draining among patients with TFV can be associated with communicating syringomyelia. An early detection and treatment seems important on resolving syringomyelia and avoiding permanent neurological deficits. Ventriculo-peritoneal shunt in trapped fourth ventricles can resolve a secondary syringomyelia. Full article