Gangrenous Changes Research Articles

Improving Diagnosis of Acute Cholecystitis with US: New Paradigms.

Acute cholecystitis is an inflammatory condition of the gallbladder typically incited by mechanical obstruction. Accurate diagnosis of this common clinical condition is challenging due to variable imaging appearances as well as overlapping clinical manifestations with biliary colic, acute hepatitis, pancreatitis, and cholangiopathies. In acute cholecystitis, increased dilatation and high intraluminal pressures lead to gallbladder inflammation and may progress to gangrenous changes, focal wall necrosis, and subsequent perforation. In acute calculous cholecystitis, gallstones are the cause of obstruction and are often impacted in the gallbladder neck or cystic duct, leading to gallbladder inflammation. In acalculous cholecystitis, patients are typically critically ill, often with hypotensive episodes and prolonged gallbladder stasis, which lead to obstruction, gallbladder ischemia, and inflammation. Helpful sonographic findings of acute cholecystitis include a dilated gallbladder; increased intraluminal pressures in the gallbladder, resulting in a bulging fundus (tensile fundus sign); intraluminal sludge in the setting of right upper quadrant pain; wall hyperemia, which may be quantified by elevated cystic artery velocities or hepatic artery velocities; mucosal ischemic changes, characterized by loss of mucosal echogenicity; pericholecystic inflammation, characterized by hyperechoic pericholecystic fat; and mucosal discontinuity. Extruded complex fluid next to a wall defect is definitive for gallbladder wall perforation, and further evaluation with CT or MRI allows evaluation of the full extent of perforation and other potential complications. The sonographic Murphy sign, while helpful if positive, is relatively insensitive for accurate diagnosis of acute cholecystitis. Thus, overreliance on the sonographic Murphy sign results in surprisingly low diagnostic accuracy in practice.

PRESENTATIONS AND OUTCOMES OF AORTOFEMORAL BYPASS GRAFTING

Objectives: The aim of the study is to study presentations and clinical outcomes in patients undergoing Aortofemoral Bypass Grafting Surgery (AFB). Design: This was a Hospital based prospective study. Materials And Methods: During 18 months period , 20 patients (mean age = 56 years) underwent AFB. Indications comprised of occlusive disease with Intermittent Claudication (IC) (n=10), Critical Limb Ischaemia (CLI)(n=4), Resting Pain (RP) (n=4) and Tissue Loss (TL) (n=2). Results: From Jan 2023 to June 2024, AFB was performed more frequently for IC (50%) vs rest of other indications. 30 day observations / follow up showed infection in 5%, Graft occlusion in 5% for which patient underwent emergency graft thrombectomy, Amputation in 10% due to gangrenous changes and 15% mortality. Graft patency was found to be triphasic in 90% cases. Hypertension was leading risk factor (85%) followed by Diabetes Mellitus(70%) and smoking (65%). Predictors of morbidity included CKD (25%), CAD (25%), COPD (20%), CVA (20%).90% Patients were operated via thoracotomy approach and 10% were operated via abdominal approach depending on level of aortic thrombus. 20% of patients had previous history of endovascular interventions followed by stent occlusion. Conclusion: In era of endovascular intervention, Aortofemoral Bypass Surgery is more likely to be performed for Intermittent Claudication and graft patency has a better outcome.

Assessment of Early Laparoscopic Cholecystectomy in Management of Acute Calcular Cholecystitis

Abstract Background Acute cholecystitis is one of the most significant diseases in the Western world and has a high socioeconomic impact. Mainly, patients with gallstones and older adults are affected. The main complication of acute cholecystitis is recurrent biliary colic and cholestasis. The latter may lead to ascending cholangitis, and while this can be managed with antibiotics, other complications cannot be cured conservatively such as gangrenous changes, gall bladder perforation and biliary leakage, and acute necrotic gallstone pancreatitis. Liver abscesses and underlying incidental carcinoma have also been reported in some cases. Aim of the Work The purpose of this study is to focus on success rate of early laparoscopic cholecystectomy as a management of acute calcular cholecystitis along with its operative and post- operative outcomes. Patients and Methods This is a prospective cohort study conducted on forty (40) patients presenting to Ain-Shams University hospitals and authorized hospitals presented with acute calcular cholecystitis starting from January 2021 and December 2021. Results Our study demonstrates that in terms of morbidity and mortality, early laparoscopic cholecystectomy is safe, feasible and cost-effective for cases of acute cholecystitis. The outcome of the patients in our study provides further evidence that early laparoscopic cholecystectomy can be performed within the first 72 hours of symptoms with no significant increase in length of operation. Moreover, there was no significant increase in the rate of major intra operative or post operative complications such as bleeding, bile duct injury, bowel injury, wound infection and conversion to open cholecystectomy. The major advantage of early cholecystectomy was that early laparoscopic cholecystectomy allows significantly shorter total hospital stay and reduction in days away from work. Moreover, it avoids repeated admissions for recurrent symptoms. Conclusion Early laparoscopic cholecystectomy is safe, feasible and cost-effective for cases of acute cholecystitis and its major advantage is that it allows significantly shorter total hospital stay and reduction in days away from work and avoids repeated admissions for recurrent symptoms.

An Analysis of the Impact of Intra-abdominal Pressure on Surgical Outcomes in Cases of Intestinal Obstruction: A Prospective Observational Study.

The decision and timing of surgical exploration of intestinal obstruction depend on the clinical findings and probable etiology of the symptoms. Patients with intestinal obstruction often have intra-abdominal hypertension (IAH), which is associated with a poor prognosis. The purpose of the study is to evaluate the surgical outcomes in patients with intestinal obstruction in relation to intra-abdominal pressure (IAP). The study was conducted on 50 patients with intestinal obstruction undergoing surgery. Preoperatively, IAP was measured in all the patients and was allocated into two groups based on the presence or absence of IAP. Patients were assessed for the postoperative length of hospital or ICU stay, surgical site infection, wound dehiscence, and recovery following surgery. The patients with preoperative IAH had significantly longer postoperative stays, with a median stay of eight days in these patients compared to four days in patients without IAH (p=0.009). A significantly higher number of patients (24%) had gangrenous changes on the bowel wall (p=0.042) and fascial dehiscence (p=0.018) in the group associated with raised IAP. A total of 75% of patients who required ventilator support belonged to the raised IAP group. The mean IAP in patients admitted to the ICU was significantly higher than in patients not admitted to the ICU (p=0.027). Preoperative IAH in intestinal obstruction is a significant factor in predicting the possibility of bowel ischemia with gangrene, perforation, intra-abdominal sepsis, surgical site infections, and prolonged hospital stay. Early surgical exploration and abdominal decompression must be considered in such cases.

A Rare Case of Symmetrical Peripheral Gangrene in Central Venoarterial Extracorporeal Membrane Oxygenator in a Pediatric Patient, an Unusual Complication of Extracorporeal Membrane Oxygenation

Symmetrical peripheral gangrene is an unusual complication of extracorporeal membrane oxygenation (ECMO) which can arise due to low cardiac output state, high inotropic support, inadequate anticoagulation, disseminated intravascular coagulation, and sepsis. In symmetrical peripheral gangrene, there is no evidence of large vessel occlusion or vasculitis. It can be due to the absence of pulsatile flow in the peripheral arteries that result in stasis and microthrombi formation which causes occlusion of small arterioles. A 10-month-old male child who underwent anomalous left coronary artery from pulmonary artery repair and required central venoarterial ECMO support post-surgery due to severe myocardial dysfunction developed symmetrical peripheral ischemia with gangrenous changes in the right-hand fingers while on extracorporeal membrane oxygenation (ECMO). The limb ischemic changes improved to normal after the child convalesced from heart failure. We describe these changes and the management here.

Symmetrical Fingertip Gangrene in a Factory Worker Exposed to Paint Thinner

Symmetrical peripheral gangrene involving the fingertips is a frequent manifestation of atherosclerotic or embolic thrombi. It may indicate an underlying systemic vasculitis or suggest an environmental exposure to freezing temperatures. We present a case of a factory worker who inadvertently got exposed to paint thinner at workplace, leading to gangrenous changes in his exposed fingertips. The clinical examination and investigations could not reveal any inflammatory or hypercoagulable state, and arterial vasospasm was found to be the most possible reason attributable to this event. The patient was managed with antiplatelet drugs and arterial vasodilators. In a case of bilateral symmetrical finger gangrene, physicians must systematically search for a professional or occupational as a putative factor.

Epidemiology and acute management of high tension electrical burns in a rural-based medical college

Introduction. Electrical burns are one of the most common causes of burns besides flame burns and scalds. High tension electrical burns lead to greater morbidity and mortality. Active management strategies are required to manage high tension electrical burns. Common epidemiological features and surgical management of wounds are described. Role of high ligation in high tension electrical burns has been described.Purpose. To describe the epidemiology, main features of the presentation and acute management of high tension electrical burns.Materials and methods. This study was done for the duration of 2 months. All patients who were admitted with high tension electrical burns were included in the study. Patients’ demographics, mode of injury, % age of burn areas involved, entry-exit wounds were recorded on the day of admission. Emergency fasciotomy was done in cases of impending gangrenous changes inlimbs to prevent compartment syndrome and peripheral neuropathy. Reconstructive surgeries were done depending on thelocation and depth of burns. Results. 64% patients were below 30 years. The majority of the patients who sustained electric burns were males (82.3%). All the patients were from low and middle socioeconomic status according to the modified kuppuswamy scale. The majority of patients sustained electric contact burns (55.8%). The majority of the patients were unskilled workers working in the fields (94.2%). Surgical treatment of all patients includes fasciotomies in 15 patients, debridement/ amputation in 32 patients, reconstructive surgeries in 42 patients.Conclusion. High tension electrical burns are one of the most common causes of burns, especially in rural areas. Public awareness and compliance with safety standards as well as respect for the potentially deleterious effects of electricity are of utmost essential for avoiding these deadly injuries.

“Clinicoradiological Score – Valuable Tool to Assess the Risk of Strangulated Small Bowel Obstruction in Tertiary Care Center”

Objectives Small bowel obstruction accounts for about 3% of the emergency laparotomies, hence there is a need for early recognition of the risk associated with strangulated small bowel obstruction. However, there is no single reliable tool for evaluating the bowel strangulation risk precisely and quickly, hence we sought to assess the specificity and sensitivity of a scoring system named “Clinicoradiological score” as a tool to assess the risk of strangulated small bowel obstruction in tertiary care center for early intervention. Material and Methods The study was an observational study conducted on 50 patients with clinical symptoms of small intestinal obstruction, diagnosed by CT and admitted in-patient basis at the general surgery department in the hospitals attached to Bangalore Medical College and Research Institute, Bengaluru from November 2017 to May 2019. In this scoring system, one point was given to each factor which includes pain duration (4 or more days), guarding, leucocyte count at least 10 ×109/L, C-reactive protein 75 mg/L or more, free fluid at least 500 mL (CT criteria), reduced wall contrast enhancement (CT criteria) leading to a maximum score of 6. Based on standard treatment outcome, patients were grouped into three categories (conservative management, laparotomy without resection and anastomosis, and laparotomy with resection and anastomosis). Data was analyzed by descriptive statistics. The risk factors were compared between three patient groups and Chi-square test used for hypothesis testing. Sensitivity and specificity were evaluated for accuracy of score. Results Out of the six factors of Clinicoradiological score, five factors were found to be predictors (p-value <0.01), while history of pain more than 3 days did not have a significant p-value. In our study all 18 patients with score more than 3 had gangrenous changes and underwent resection. The p-value of the score was found to be significant. Conclusion Clinicoradiological score has been proved to be a valuable tool in predicting the risk of strangulated small bowel obstruction and ascertained the need for subsequent intestinal resection.

PENILE CALCIPHYLAXIS: AN EXPERIENCE OF TWO CASES MANAGED AT A TERTIARY CARE CENTRE

Penile calciphylaxis is a rare complication of end-stage renal disease, & occurs as a manifestation of calcic uremic arteriolopathy, leading to necrosis and gangrenous changes in the penis. Also, penile calciphylaxis is a late manifestation in the course of end-stage renal disease, and potentially a forerunner of more sinister events to follow, such as mortality. Despite the rich vascular supply of the penis, this uncommon affectation of the penis by uremic arteriolopathy is an intriguing entity for urologists & nephrologists alike, and no formal management protocol or guidelines exist for successful management of such cases. We present 2 such cases of penile calciphylaxis which were managed at our institution

Cecal gangrene – Unusual complication of manual bowel decompression

We present a case of a 31-year-old female who presented with complaints of obstipation. Imaging features were suggestive of small bowel obstruction with transition point at distal ileum. On emergency laparotomy, the patient was found to have fecal impaction, for which manual bowel decompression (milking) was done. The patient developed hypotension intraoperatively requiring ICU admission for post-operative management. Post-operative CT demonstrated features of hypotension with gangrenous changes in the cecal wall. Re-exploration surgery demonstrated features of cecal gangrene consistent with imaging findings.

Iatrogenic-induced Peripheral Gangrene: From Multiple Limb Amputations to Prosthetic Restoration

Objectives: Multiple limb amputations are an uncommon complication from inotrope-induced peripheral gangrene. Case Presentation: A 20-year-old lady with valvular heart disease had septic shock secondary to infective endocarditis and required prolonged cardiopulmonary resuscitation. Despite aggressive fluid resuscitation, the patient had triple strength intravenous noradrenaline to maintain hemodynamic stability. On day 5 of post-shock, dry gangrene occurred in distal parts of all limbs, and inotrope was stopped. Although the gangrenous changes were non-progressive, she required a significant degree of assistance with mobility and daily function performance. The patient was counseled for multiple limb amputations to promote walking and hand function through prosthetic restoration. Five months after the event, she had a right transtibial amputation, left Chopart amputation, left wrist disarticulation, and right second, third, fourth, and fifth fingers amputation. Three specific goals for inpatient rehabilitation were independent short-distance ambulation with prostheses, performing basic activities of daily living with adaptive devices, and independent wheelchair propulsion for long-distance mobility using a right-sided transtibial prosthesis, left-sided Syme's prosthesis with Kingsley's foot, right-sided silicone-based cosmetic glove and left-sided body-powered transradial prosthesis. Discussion: Although an uncommon complication, inotrope may lead to multiple limb amputations secondary to peripheral gangrene. Following amputation, the ultimate rehabilitative goal is to restore the mobility and capacity to perform daily functions through prosthetic restoration, whether walking for lower amputees or functioning hand for upper limb amputees. Prescribing prosthesis in a single limb loss is relatively straightforward, but restoring multiple limb amputations bears many challenges toward successful recovery of walking and functions.

Case Report: Extensive Gangrene: A Rare Presentation of Multisystem Inflammatory Syndrome in Children

A wide spectrum of cutaneous manifestations are reported in multisystem inflammatory syndrome in children (MIS-C). However, gangrenous changes are less frequently reported. A 3-year old boy, with a known case of unoperated tetralogy of Fallot, presented with a short history of fever, rash, and melena. The rash was black and diffuse, with a rapid progression. The patient was stable hemodynamically at admission, with pallor, grade II clubbing, edema, and oral ulcers. Inflammatory markers were raised. He developed gangrenous changes over the ears and acral areas. He had very high levels of antibodies to severe acute respiratory syndrome coronavirus2 (SARS-CoV-2) infection and was diagnosed as having MIS-C. Skin biopsy revealed near total epidermal necrosis with dermal vascular thrombi and negative immunofluorescence. Skin biopsy was positive for IgG antibodies to SARS-CoV-2. He was treated with antibiotics, immunomodulation with steroids, intravenous immunoglobulin, and plasmapheresis. He had features of both micro- and macroangiopathy. Gradually the child improved, with residual deformity.

Imaging of acute appendicitis: Advances.

We read with interest the review by Teng et al, who summarized the current approach to the diagnosis and treatment of acute appendicitis (AA). Also, the article summarizes the clinical scoring systems very effectively. In one of the previous studies conducted by our research group, we showed that the use of the Alvarado score, ultrasound and C-reactive protein values in combination provides a safe confirmation or exclusion of the diagnosis of AA. Computed tomography is particularly sensitive in detecting periappendiceal abscess, peritonitis and gangrenous changes. Computed tomography is not a good diagnostic tool in pediatric patients because of the ionizing radiation it produces. Ultrasound is a valuable diagnostic tool to differentiate AA from lymphoid hyperplasia. Presence of fluid collection in the periappendiceal and lamina propria thickness less than 1 mm are the most effective parameters in differentiating appendicitis from lymphoid hyperplasia. Although AA is the most common cause of surgical acute abdomen, it remains an important diagnostic and clinical challenge. By combining clinical scoring systems, laboratory data and appropriate imaging methods, diagnostic accuracy and adherence to treatment can be increased. Lymphoid hyperplasia and perforated appendicitis present significant diagnostic challenges in children. Additional ultrasound findings are increasingly defined to differentiate AA from these conditions.

GIANT INGUINOSCROTAL HERNIA - A RARE CASE MANAGED AND REVIEW OF LITERATURE

Massive inguinoscrotal hernias are rare hernias that extend below the midpoint of the inner thigh, in the standing position. We present a case of a 66- year-old patient with a very large irreducible bilateral direct inguinal hernia, without signs of obstruction or gangrenous changes. The patient was taken up for surgery under general anesthesia after optimizing the patient using preoperative incentive spirometry and nebulization. We used the laparoscopic transabdominal preperitoneal laparoscopic(TAPP) approach to reduce the hernial content which was followed by Lichtenstein's open bilateral inguinal hernioplasty. The patient was kept sedated and paralyzed on ventilatory support in intensive care for 2 days. Management of giant hernia is challenging due to various problems such as loss of domain, intraoperative cardiorespiratory complications, increase in intra-abdominal and intrathoracic pressures. Even after successful management recurrence is another complication faced when compared to other inguinoscrotal hernias. We describe laparoscopic reduction along with open bilateral inguinal hernioplasty as a viable technique in this patient followed by elective ventilation in the postoperative period. He did not require bowel resection as adequate abdominal relaxation is attained with this approach.

Enterobacteriaceae opportunism isolated from Caspian Turtle Mauremys caspica (Gmelin, 1774) suffering from a fracture of the external shell, East of Al-Hammar Marshes, Iraq

Caspian Turtles Mauremys caspica (Gmelin, 1774) are classified as an endangered species on the IUCN red list, by a variety of dangers including hunting, deliberate killings and infectious diseases. The present report included the Opportunistic bacterial isolation which caused clinical signs on the M. caspica Turtles caught from the East Al-Hammar freshwater marshes, during summer 2017. It was suffering from a fracture of the external shell, tissue damage, bacterial growth and acute inflammation of the body tissues. The common clinical signs were external hemorrhage, histopathological changes revealed degeneration and necrosis in all organs associated with chronic inflammatory cell infiltration and Melanomacrophage cells were detected in all turtle tissues. The most common macroscopic lesions found on the skin of the turtle and ulcerative skin, the result in abscesses and dermatitis, regenerative changes on skin lesions and ulcerative deep necrotic and gangrenous changes in the turtle examined. Four different genera of family Enterobacteriaceae which identified by the VITEK II system, with a probability level of 94-99%, Citrobacter freundii (29.06%), Klebsiella oxytoca (25.58%), Serratia fonticola (24.41%) and Enterobacter cloacae (20.41%). The result showed that of a total of sixty-five bacterial isolates from the necrotic lesions skin tissue, some of them which are considered a potential threat to the public health.

The efficacy of primary closure following incision and drainage of lactational breast abscess over traditional open method

Background: The incidence of breast abscess ranges from 0.4 to 11% of all lactating mothers. Although breast abscess is a serious common complication of mastitis with high morbidity rate, there is a lack of high-quality randomized trial to demonstrate the best treatments.Methods: The Study was conducted in the Department of Surgery of Universal medical college and hospital, Dhaka, Bangladesh and MH Samorita hospital and medical college. It was a randomized controlled trial to see the efficacy of primary closure following incision and drainage of lactational breast abscess over traditional open method. Total 120 population were randomly selected in group A (60 patients) and group B (60 patients) and data was collected with their signed ethical consent. The study was conducted from January 2014 to December 2019. Collected data were classified, edited, coded and entered into the computer for statistical analysis by using Statistical package for social sciences (SPSS) version 22.Results: In patients of group A, most breast abscesses healed successfully with a nicer circumareolar scar, earlier healing, lesser number of hospital visits and lower total cost as compared to patients in group B. There was early resumption of breastfeeding and better patient satisfaction seen in group A.Conclusions: Primary closure of lactational breast abscess following incision and drainage is an effective modality of treatment of lactational breast abscess and it should be the first line of treatment, especially for larger and multilocular breast abscesses while traditional incision and drainage should be reserved for abscesses with gangrenous skin changes, where primary closure is not justified.

Impacted Ring in the Penis: A Crisis Rescued by Plier

A trapped penile ring is a urological emergency rarely seen. An impacted ring in penis is a real emergency uncommonly faced by a urologist. Emergent removal of the penile ring is indicated to prevent gangrene and damage to the penis. The insertion of these rings for autoerotic purposes is not uncommon. However, this can lead to impacted, stuck articles, rings in the penis. These patients present with symptoms ranging from mild penile pain, swelling to gangrenous changes in the penis. The removal of ring constricting penis is a penile-saving procedure. We describe a patient with a stuck ring in the penis and the technique of removal of the impacted penile ring by a household device plier. In case of emergency, the pliers are a useful tool for removing a strangulating penile ring

Hyperinfection with Strongyloides stercoralis presenting as acute abdomen in a patient on corticosteroid therapy: A case report.

Infection with Strongyloides stercoralis, a human pathogenic roundworm, is common in tropical countries like India. Owing to its variable clinical presentation and irregular larval output in stool, it often remains neglected and underdiagnosed. Signs and symptoms are largely dependent on the immune status of the infected individual. Alteration in the host immunity due to chronic use of steroids can surge the number of parasites and cause hyperinfection syndrome. This can be catastrophic with a fatal outcome. Focus on early detection and treatment of the parasite in at-risk patients is imperative to reduce mortality. We summarize here an interesting case of hyper infection syndrome of strongyloidiasis with gangrenous bowel changes later progressing to burst abdomen.

Management of necrotizing fasciitis of neck – Our experience

Necrotizing fasciitis is a severe bacterial infection characterized by progressive necrosis of the fascia and subcutaneous tissue. Even though it rarely involves the cervical region, this condition carries high mortality rate. So, it requires prompt diagnosis and urgent treatment with extensive debridement and adequate antibiotics.50yrs old man presented with a rapidly progressing ulcer on left side of face and neck with extensive gangrenous changes of the surrounding skin. He was a known case of diabetes mellitus and was on irregular medication. Underwent extensive debridement within 12 hours of presentation and managed with antibiotics and Vacuum assisted dressing. Strict diabetic control achieved with the help of insulin.Satisfactory outcome can be achieved by early diagnosis, aggressive surgery along with adequate antibiotic therapy and strict diabetic control. Vacuum assisted closure helps in early recovery.

Acute Kidney Injury in a Case of Multiorgan Failure, Disseminated Intravascular Coagulation and Purpura Fulminans

Introduction Purpura fulminans (PF) is a life-threatening syndrome consisting of Disseminated Intravascular Coagulation (DIC), thrombotic occlusion of small- and medium-sized blood vessels with skin necrosis. Although there are few studies in the literature, only a minority of them discuss renal manifestations. Case Report We present a case of a 57-year-old Caucasian female with acute kidney injury (AKI) in the setting of multiorgan failure (MOF), DIC and PF. She presented with fever, exudative drainage from her port site, and skin changes concerning for bacteremia. Empiric antibiotics were started after blood, urine, and wound cultures were obtained. None of the cultures grew any organisms. Fever resolved after port removal. She exhibited thrombocytopenia, leukopenia, and neutropenia. Urinalysis showed hyaline casts and a fractional excretion of urea (FeUrea) ≤35% indicating a pre-renal state. Her hospital course was complicated by atrial fibrillation, acute hypoxic respiratory failure requiring mechanical ventilation, and hypovolemic shock requiring pressor support. Further, complicated by multiorgan failure including non-oliguric AKI and heart failure with reduced ejection fraction (HFrEF) of ≤65%. Acute skin findings included dusky, purple macules and patches involving all digits of both hands as well as gangrenous changes on the face and toes. It prompted further investigation by Hematology and Dermatology. Skin biopsy showed early leukocytoclastic vasculitis changes. Her laboratory markers were suggestive of DIC and Purpura Fulminans.