Subclavian Steal Syndrome

Abstract Hyoscine butyl bromide, an anti-spasmodic is often used for alleviation of colicky abdominal pain. Few studies have shown its safety and efficacy in children. Apart from common side effects, acute psychosis has been rarely reported. With this case report, we would like to reflect a message that hyoscine butylbromide should be used carefully in children, along with the emphasis on the correct dose, frequency and competency of the practicing clinician.

Hyoscine butylbromide associated psychosisDurga Neupane1, Nimesh Lageju1, Lokesh Shekher Jaiswal2B.P. Koirala Institute of Health Sciences, Dharan, NepalDepartment of Surgery(Division of CTVS), B.P. Koirala Institute of Health Sciences, Dharan, NepalAuthorsDurga NeupaneEmail: [email protected] iDhttps://orcid.org/0000-0002-9736-9335

A document by Narendra Pandit. Click on the document to view its contents.

Left segmental hypoplasia of liver with concomitant gallbladder agenesis

Recurrent Pyogenic CholangitisA 59-year-old South Asian female presented with the complain of pain upper abdomen and recurrent fever for one year. There was no history of vomiting, jaundice, anorexia or weight loss. Family history was unsupportive of diagnosis. On laboratory examination, alkaline phosphatase was elevated by two times. Serum bilirubin was normal and her leukocytes count was 11200/mm3. Rest of the systemic examination was normal. Contrast enhanced computed tomography(CECT) revealed multiple hypodense/hyperdense lesion in segment 3 of liver. Magnetic resonance imaging(MRI) showed hypo-hyperdense focal lesions with conglomerate appearance on segment 3 of liver suggestive of hepatolithiasis (Figure 1). Left lateral segmental resection (Figure 2) and intrahepatic choledochoscopy from dilated left hepatic duct and stone clearances was done. On histopathological examination, definitive diagnosis of recurrent pyogenic cholangitis was established with no evidence of malignancy. At a 3-year follow-up, the patient is free of recurrence.The incidence of hepatolithiasis is variable. It is highly prevalent in parts of Asia, such as China, Japan, and South Korea, with a reported incidence between 3.1% and 21.2%.1 However, with an incidence of about 1%, hepatolithiasis is rare in Western countries.The mechanism of development of hepatolithiasis is yet to be fully elucidated. Cholestasis, cholangitis, an anatomical abnormality of the bile ducts, abnormal bile metabolism, malnutrition, and low socio-economic status are significant risk factors for hepatolithiasis. According to several studies, indications of hepatectomy for hepatolithiasis include the following instances: (i ) unilobar hepatolithiasis, and particularly that on the left; (ii ) atrophy or severe fibrosis of the affected liver segments or lobe; (iii ) presence of a liver abscess; (iv ) cholangiocarcinoma; and (v ) multiple intrahepatic stones causing marked biliary stricture or dilation.2 Globalization, apart from changing the socioeconomic status of regions, has additionally altered disease dynamics globally. Hepatolithiasis, as a result of recurrent pyogenic cholangitis, although still rare, is becoming progressively evident in the West because of immigration from the Asia-Pacific region, where the disease is endemic. Such rare but emerging disease has imposed significant challenges to the physicians and surgeons. Uenishi et al.3 presented outcomes for 86 patients who underwent a hepatectomy from 1998 to 2012. Seventy-six patients (88%) had immediate stone clearance whereas 82 patients (95%) had final stone clearance.3 A multi-disciplinary team approach involving radiologists, internists, pathologists, oncologists, and surgeons is deemed necessary for the timely diagnosis and safe, affordable treatment, thus ensuring good prognosis to the patients.Low socio-economic status of our patient could have been the attributing factor. Also, unilobar hepatolithiasis, and particularly that on the left was the main indication for left lateral segmental hepatectomy in our case. With this image, we would like to recommend that the differential diagnosis of hepatolithiasis should be thought in the back of mind if an elderly person from endemic region presents with the complain of pain upper abdomen and recurrent fever. Surgical intervention is deemed necessary with the aforementioned indications and it can provide good prognosis to the patient with an excellent stone clearances.Conflict of interests: NoneConsent: Written informed consent was obtained from the patient for the accompanying images.

Title: Blunt trauma abdomen with isolated infarcted left lateral segment of the LiverA 13-years-old female presented to the emergency surgical department with pain epigastrium, and shortness of breath for 3 days. She sustained blunt abdominal trauma following motor vehicle accident three days back. Following the injury, she was initially managed at the periphery hospital; on deterioration was referred to our academic tertiary care center. On general physical examination, she was conscious, oriented, febrile, tachypneic (28 breaths/min), tachycardic (130 beats/min) with normal blood pressure. There was no pallor. Abdominal examination revealed tender epigastrium with guarding. Her blood investigation showed normal hemoglobin, leukocytosis (22,000/mm3), normal renal function tests and amylase/lipase levels, normal bilirubin but raised liver enzymes (>3 times). On contrast computed tomography (CT), there was a well-demarcated, absence of perfusion on the left lateral segment to the liver suggesting infarction (Fig. 1). The hepatic arteries, portal vein and its branches and other abdominal organs were normal. There was no intrabdominal collection. Diagnosis of traumatic left lateral liver segment infarct with sepsis, probably from the bile leak from the divided liver segment was assumed, and planned for surgery.At surgery, there was a near complete (70%) detachment of the left lateral segment of the liver from the falciform ligament. The injured segment was dusky brown, pale and stained with bile leak (Fig. 2 and 3). It was resected (left lateral segmentectomy), hemostasis secured and area drained. Postoperatively, she improved dramatically. Her symptoms, tachycardia, tachypnea and raised leukocytes counts improved and were discharged on day 12. The pathological examination confirmed necrosis of the excised segments. At 2- years follow-up, she is doing well.The liver is the most commonly injured organ following motor vehicle accident due to the sudden deceleration. The most frequent occurrence is a tear between liver segments III and IV caused by the acute impact of the liver on the hepatic ligament.1 This tear often leads to intraperitoneal hemorrhage; but in contrast, rarely can lead to the devascularization of the segment as observed in the present case. This is because of the interruption of flow from the left hepatic artery.2 A liver injury, despite the grade, if hemodynamically stable is preferably managed non-operatively. However, if the segment (II and III) is devascularized, with concomitant bile leak and persistent systemic inflammatory response syndrome (SIRS), it is best managed with resection of the segment with excellent outcome as seen in our case.3 This scenario with typical CT and intraoperative image is rare to see with anecdotal case reported in the literature.1

Multiple large joint swellings in an elderly alcoholic manA 65-year-old male (BMI: 23 kg/m2) with chronic hypertension under amlodipine presented with chief complaints of multiple joint swelling on bilateral hands and feet. The swelling appeared 15 years back, and gradually increased over the years. The patient had frequent pain from the swelling in the past, but instead of seeking medical attention, he took over-the-counter painkillers. He has no family history of such swellings but has a 35-year history of chronic alcohol use, smokeless tobacco use, and cigarette smoking. On examination, multiple large, firm, and immobile swellings were located over the proximal and middle phalanges along with the metacarpophalangeal joints of both hands (Figure 1). Similar swellings were present over the metatarsophalangeal joints and ankle joints of both feet (Figure 2). There was no ulceration over the swelling. On lab evaluation, his uric acid level was 9.6 mg/dl (N: 2.5-7.8 mg/dl) with a normal renal function test. Plain radiography of both hands and feet revealed significant osteolysis of the involved joint. Needle aspiration yielded white viscous fluid which showed numerous needle-shaped birefringent crystals of monosodium urate on polarized light. The patient was prescribed Allopurinol 100mg/day along with counseling on lifestyle modifications.An accumulation of monosodium urate crystals causes gout that most frequently affects the first metatarsophalangeal joint. Risk factors include increased age, alcohol use, osteoarthritis, purine-rich foods, family or personal history of gout attacks, and medications such as thiazide diuretics for hypertension.1 Hyperuricemic patients (≥ 6.8 mg/dl) can develop polyarticular tophaceous gout from intermittent arthritis if untreated. Acute flares and tophi development can be avoided by lowering blood urate levels with xanthine oxidase inhibitors or uricosuric medications. A target serum uric acid level of <6.0 mg/dl is desirable.2 Surgery is only indicated for gout in situations of repeated attacks with deformities, excruciating pain, infection, and joint damage.3Conflict of interest: NoneConsent: Written informed consent was obtained from the patient for reporting this case image.Ethical approval: Not required

In this case report, a medical sales representative consumed 250 mg of Baclofen out of curiosity. Baclofen has life-threatening complications like seizures, respiratory depression and coma. A majority of patients recover on symptomatic treatment. Baclofen has a great potential for abuse and overdose; therefore, its use must be strictly monitored

Hyoscine butylbromide induced pyschosis, though rare, should be considered in a child presenting with deteriorating cognitive functions and psychotic features acutely as evident in our case of a 9-year-old child taking hyoscine for her non-specific abdominal pain.