IIUM Medical Journal Malaysia (IMJM)
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Sawing Through The Neck - A Case of Serrated Fish Bone Migrating to Prevertebral Space
Get PDFFish bone is the commonest pharyngeal foreign body, however migrating fish bone is a rare occurrence. We report a case of a 54-year-old male who had history of fish bone ingestion over a week and presented with odynophagia and worsening neck pain. Rigid esophagoscopy revealed tip of a fish bone which was embedded in granulation tissue. The fish bone migrated further with manipulation. Aided with computed tomography scan findings, the serrated fish bone was finally removed via transcervical approach without any complication. In conclusion, high index of suspicion and prompt removal of migrating fish bone with the aid of computed tomography imaging is necessary to avoid fatal complications
Isolated Small Bowel Perforation Following Blunt Trauma
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Small bowel perforation is common following blunt abdominal trauma. Intra-abdominal injury with isolated small bowel perforation however, is a rare entity and diagnosis can be ambiguous. Nonisolated small bowel perforation, which carries a higher mortality rate, will be identified early during the assessment of the patient following a blunt abdominal trauma. A case of an isolated small bowel perforation following a road traffic accident is reported. A motorcycle rider, while trying to avoid a car, lost control and skidded into a drain. Upon arrival to the Emergency Department, he was complaining of upper abdominal pain evident by abrasion and bruising of his bilateral hypochondriacs. FAST scan showed free fluid at Morrison’s pouch and a formal abdominal ultrasound confirmed minimal free fluid at Morrison’s pouch. A plain CT abdomen was done and did not show any evidence of solid organ injury but demonstrated pneumoperitoneum. In view of the persistent abdominal tenderness, open fracture of left femur, radius and ulna, and radiological findings, a laparotomy was performed which revealed an isolated 1x1cm small bowel perforation, 60cm from DJ junction with localized faecal contamination. Small bowel repair was done and patient recovered well afterward. Although challenging, due to its detrimental infectious potential, early recognition of small bowel injury is crucial. Isolated small bowel perforation, rarely without associated intra-abdominal injury, requires more investigations, delaying diagnosis to treatment period. CT abdomen has proven to be both specific and sensitive in diagnosing small bowel injuries. Even when physical examination and radiological examinations are minimal, a suspicion of small bowel perforation should be considered as delay in diagnosis eventually increases morbidity and mortality
Primary Jejunal Intussusception in Pregnancy: Clinical Challenges in Management
Get PDFIntussusception is a common cause of abdominal pain in paediatric age group but infrequent in adults. We reported a 29-year-old lady, Gravida 2 para 1 with no known medical illness presented to the hospital at 35 weeks of gestations with complaint of abdominal pain and persistent nausea and vomiting. She had bilious vomiting more than 5 times a day which aggravated by food intake and epigastric pain. She also complained of had not passing flatus with no bowel opening 3 days prior to presentation. At presentation, she was dehydrated however not in shock and her vital signs were within normal range. Abdominal examination revealed mild tenderness over epigastric region without guarding. There was an evidence of electrolytes imbalance and kidney injury on her blood investigation. She was induced for labour due to lack of evidence of fetal signals. On day 2 post partum, she still complaining of persistent bilious vomiting, otherwise no abdominal pain. Radiologically, there is evidence to support a small bowel obstruction. An exploratory laparotomy was performed, intraoperatively noted presence of jejuno-jejunal intussusception closely related to duodenal-jejunal junction with 130cm of bowel involved in the intussusception were noted to be gangrene. Conclusion: Adult bowel intussusception is an uncommon and challenging condition for the surgeon. Intussusception in pregnancy is rare and difficult to diagnose. Preoperative diagnosis is usually missed or delayed. Abdominal CT is considered as the most sensitive imaging modality in the diagnosis of intussusception. However in pregnancy, the choice of imaging modality is ultrasonography
Right Hepatic Artery Encircle the Gallbladder: A Case Report
Get PDFDetailed knowledge of the vascular anatomy of hepatobiliary system is important for a safe cholecystectomy. We are reporting a case of aberrant type of right hepatic artery originating from superior mesenteric artery and encircles the gallbladder that has been found during laparoscopic cholecystectomy operation. We presented a 39-year-old Malay lady came to International Islamic University Malaysia Medical Centre with features of obstructive jaundice. Ultrasound of hepatobiliary system showed cholelithiasis with choledocholithiasis causing dilatation of the common bile duct. ERCP had been performed and sphincterotomy was done. Patient was planned for laparoscopic cholecystectomy. Intraoperatively, the Calot’s triangle was identified in usual manner. However, the right hepatic artery was identified encircling the gallbladder body anteriorly before entering the liver. The procedure was converted to open cholecystectomy due to anatomical variation via Kocher’s incision. Further identification upon open cholecystectomy revealed right hepatic artery originates from superior mesenteric artery runs anterior to cystic duct and encircles the gallbladder before further branches into right and left lobe of the liver. Right hepatic artery was dissected from the gallbladder and the gallbladder removed after cystic duct ligation and separation from the liver bed. On table cholangiogram showed distal CBD stone which was pushed down to duodenum with forceps? Post-operative was uneventful and patient liver functions improved. Knowledge regarding anatomical structure and variant of hepatic artery as well as cystic artery and cystic duct is important to ensure the inadvertent ligation of right hepatic artery which would leads to hepatic ischemia and necrosis
A Systematic Review on the Intervention Using Exercise Gaming to reduce Childhood Obesity
Get PDFThe worsening trend of childhood obesity is a global public health issue. Digital technology evolution is a contributing factor towards physical inactivity and obesity among children. In order to overcome this growing problem, exercise games have been introduced in early eighties to ameliorate this obesogenic environment. Exercise games utilize innovative technologies that provide an interactive environment, requiring gestures and body movements to simulate on-screen gameplay. The objective of this review is to assess the effectiveness of exercise gaming intervention in managing childhood obesity. A systematic review was performed. Six articles examining exercise video games impact on weight management among children published between January 2013 and December 2017 in the English language were selected from a total of 54 articles identified through five major search engines. Majority of the research was conducted in developed countries particularly in the United States whereby some developing countries had started with small-scale researches in this area. The result indicated that there was a significant increase in physical activity level, reduction of BMI, reduced adipose tissue composition and a positive psychological impact after the intervention of exercise games. However, the impact of exercise games on physiological and metabolic parameters were inconclusive and requires further study. In conclusion, exercise games are the effective way to combat childhood obesity, along with other modules of lifestyle
Mortality Due to Underestimation of Soft Tissue Injury and Misdiagnosis of Rhabdomyolysis
Get PDFRhabdomyolysis is characterized by the breakdown of muscle tissue, and release of intracellular muscle constituents into the blood circulation. The severity of the illness may range from asymptomatic elevation in serum muscle enzymes to a life-threatening disease. One disease may behave differently in different way in different individuals. The first patient was involved in a motor vehicle accident and developed acute kidney injury on the third day of admission. The second patient complained of lower limb weakness, and was discharged with vitamin D supplements. Both patients’ conditions were not properly diagnosed or treated, and succumbed to death. Autopsies were conducted in both cases, in which rhabdomyolysis were diagnosed. This case report emphasizes the importance of making a correct diagnosis of rhabdomyolysis Progression of the disease and its complications should be monitored closely. Timely management may save life in high risk patients
Derivation of A New Bioscore for Predicting Mortality in Sepsis
Get PDFIntroduction: Currently, there is a lack of clinically feasible and reliable method for discriminating outcome in sepsis. We aimed to derive a new bioscore for predicting mortality in critically ill patients with sepsis using a combination of biomarkers and clinical indexes. Materials and Methods: This was a secondary analysis from a prospective study involving 159 patients with sepsis admitted to an intensive care unit (ICU). Data for key variables considered for possible inclusion in the score were collected, which included: age, sex, source of admission, comorbidities, microorganism, bacteraemia, site of infection, septic shock status, baseline Simplified Acute Physiological Score II, Sequential Organ Failure Assessment (SOFA) score (total and organ sub-scores), C-reactive protein, procalcitonin and interleukin-6 (IL-6). Approximate quintiles of each variable were given points as per the strength of their association with 30-day mortality. Results: In accordance with the statistical significance in the logistic regression analysis, the final score utilised candidate variables of age, central nervous system and liver SOFA sub-scores and IL-6. The bioscore predicted 30-day mortality with a very good performance [area under the receiver operating characteristic curve 0.814 (95% confidence interval 0.745-0.871, p< 0.0001)] in our sepsis cohort. A bioscore greater than 4 predicted 30-day mortality with 80.4% sensitivity, 69.9% specificity, 2.67 positive likelihood ratio and 0.28 negative likelihood ratio. As the score increased, so did mortality rate. Conclusion: A new bioscore combining age, central nervous system and liver SOFA sub-scores and IL-6 measured on ICU admission potentially improves prediction of mortality in sepsis. Further study is warranted to prospectively validate the clinical utility of this bioscore in risk-stratifying patients with suspected sepsis
Intraductal Papillary Mucinous Neoplasm Presenting as Bleeding Duodenal Mass: A Surgical Rarity
Get PDFIntraductal papillary mucinous neoplasm (IPMN) is a rare pancreatic neoplasm. The presentation varies from recurrent pancreatitis, steatorrhea and weight loss to incidental findings during imaging studies. The recognition of IPMN is crucial in deciding for prompt surgical intervention, which is the best treatment modality for this precancerous condition. Here, we report a case of 55-year-old man with massive upper gastro intestinal bleeding arising from a huge fungating duodenal mass. In view of massive bleeding, a decision for emergency Whipple's pancreaticoduodenectomy was made. Final histological diagnosis confirmed as IPMN. To the best of our knowledge, this is the first case of IPMN presented with a huge fungating duodenal mass causing massive UGIB requiring surgical intervention
Reliability and Validity of the Malay Version of Edinburgh Postpartum Depression Scale (EPDS) When Administered to Postpartum Mothers at Two Points in Time
Get PDFIntroduction: Edinburgh Postpartum Depression Scale (EPDS) is a tool used to assess the risk of postpartum depression (PPD). In this study we determined the reliability and validity of the Malay version of EPDS when administered at two different time points in the postpartum period. Materials and Methods: This cross-sectional study design was carried out between May and September 2017 at three government primary healthcare clinics located in Batang Padang district, a suburban area of Perak state in Peninsular Malaysia. We recruited a total of 89 women; 41 women were in the early postpartum period (1-30 days) and 48 women were in the late postpartum period (31-120 days). Cronbach's alpha coefficient, inter-item correlation, and corrected item-total correlation were used to assess the internal consistency. The concurrent validity was assessed using Spearman’s correlation. The data were analyzed using SPSS version 20 and R 3.4.2. Results: The Cronbach’s alpha for the first and second group was 0.78 and 0.62, respectively, which indicated satisfactory reliability. At both time periods, removing Item 2 from the scale resulted in a significant increase in Cronbach’s alpha (to 0.847 and 0.709, respectively). As expected, the EPDS scores correlated moderately with the BDI-II scores (1−30 days: Spearman's rho = 0.65, p < 0.01; 31−120 days: Spearman's rho = 0.73, p < 0.01). Conclusion: The Malay version of the EPDS is a reliable screening instrument for detecting postpartum depression. It showed reasonability and feasibility and can be used in postpartum clinical settings or for assessing intervention effects in research studies. Furthermore, as our results indicated, removing Item 2 from the Malay version would increase the internal consistency of the EPDS
Ruptured Testicular Abscess: A Rare Complication of Epididymo-Orchitis
Get PDFEpididymo-orchitis is a medical condition characterised by inflammation of epididymis and testis which is a common urological diagnosis encountered by healthcare professionals. Misdiagnosis and under treatment can lead to poor outcome such as infarction and abscess formation. We presented a 33-year-old man, with no known medical illness, presented with one-week history of left testicular pain, swelling and fever. He was commenced on Amoxicillin by his general practitioner. Physical examination showed left swollen and tender testis and normal right testis. Investigations showed an elevated white cell count (WCC) 41.3x103 /L and colour doppler ultrasound (USG) testes showed left epididymo-orhitis. He was admitted and treated with IV Unasyn® (Ampicillin+Sulbactam) for 5 days. His symptoms improved, and he discharged home well with one week oral Unasyn®. He represented 2 weeks later with worsening left scrotal swelling and pain. Clinical examination found a swollen, tender and erythematous scrotum with 1x1cm defect in the left scrotum with purulent discharge. He underwent operation incision and drainage of left scrotum and left orchidectomy. Post-operatively he recovered well. Histopathology reported as epididimoorchitis with abscess, necrosis and perforation. As a conclusion, testicular rupture and abscess formation secondary to epididymo-orchitis is an uncommon reported complication. Immediate recognition and treatment is crucial as a delayed diagnosis can lead to sepsis and infertility