Biofilm and wound healing: from bench to bedside

The bubbling community of microorganisms, consisting of diverse colonies encased in a self-produced protective matrix and playing an essential role in the persistence of infection and antimicrobial resistance, is often referred to as a biofilm. Although apparently indolent, the biofilm involves not only inanimate surfaces but also living tissue, making it truly ubiquitous. The mechanism of biofilm formation, its growth, and the development of resistance are ever-intriguing subjects and are yet to be completely deciphered. Although an abundance of studies in recent years has focused on the various ways to create potential anti-biofilm and antimicrobial therapeutics, a dearth of a clear standard of clinical practice remains, and therefore, there is essentially a need for translating laboratory research to novel bedside anti-biofilm strategies that can provide a better clinical outcome. Of significance, biofilm is responsible for faulty wound healing and wound chronicity. The experimental studies report the prevalence of biofilm in chronic wounds anywhere between 20 and 100%, which makes it a topic of significant concern in wound healing. The ongoing scientific endeavor to comprehensively understand the mechanism of biofilm interaction with wounds and generate standardized anti-biofilm measures which are reproducible in the clinical setting is the challenge of the hour. In this context of "more needs to be done", we aim to explore various effective and clinically meaningful methods currently available for biofilm management and how these tools can be translated into safe clinical practice.

Enterolith Causing Small Bowel Obstruction: Report of a Case and Review of Literature

Enterolithiasis, also known as gastro-intestinal concretions, is an uncommon medical disorder that arises from intestinal stasis. Enteroliths are commonly caused by tuberculosis-related constriction and arise from intestinal diverticula. Small bowel obstruction caused by an enterolith is extremely uncommon and might be difficult to diagnose. The mortality rate of uncomplicated enterolithiasis is relatively low, but it rises to 3% in patients who have background comorbid illness, have significant bowel obstruction, and are diagnosed late. We present a rare case of an uncomplicated partial intestinal obstruction caused by an enterolith in an elderly male patient with small bowel diverticular disease who was treated nonoperatively and did not develop further symptoms in the six-month follow-up and discuss the difficulty in diagnosis and its management.

Wandering Spleen and Acute Gastric Volvulus in an Elderly Woman with Acute Abdomen: A Case Report

Gastric volvulus is an uncommon clinical condition with the potentially life-threatening complication of acute gastric necrosis. A wandering spleen may also be associated with gastric volvulus and can produce a diagnostic dilemma as the cause of an acute abdomen. We present a case of an elderly woman who presented with acute abdominal symptoms. She did not have the classical Borchardt triad to diagnose gastric volvulus and had a coexisting wandering spleen. Although torsion and ischemia of the wandering spleen were initially thought to be the cause of acute abdomen, a subsequent contrast-enhanced CT (CECT) scan confirmed a coexistent mesenteric-axial gastric volvulus with gangrenous changes. We present this case to highlight a rare combination of pathologies, either of which can confuse the diagnosis or cause a delay in management. Early diagnosis with CECT is emphasized, and segmental resection is feasible when the rest of the viscus can be preserved.

Superior Mesenteric Artery Syndrome as a Rare Cause of Postoperative Intractable Vomiting: A Case Report

BACKGROUND

Superior mesenteric artery syndrome is a very rare cause of proximal intestinal obstruction. The objective of this clinical case report is to highlight that this unusual condition can occur in the early postoperative period and medical management may completely cure the condition.

CLINICAL CASE

A middle-aged female who was being treated for pulmonary tuberculosis underwent exploratory laparotomy with limited ileal resection and a loop ileostomy for multiple ileal perforations. Postoperatively, she was restarted on anti-tubercular drugs (ATD) but developed a drug reaction, recurrent bilious vomiting, and jaundice and ATD had to be stopped. But her vomiting did not abate and she progressively developed septicemia. An abdominal CT scan diagnosed Wilkie's syndrome, and she was managed non-operatively by decubitus, parenteral nutrition, and nasojejunal tube feeding supplemented with prokinetics and antibiotics. But her sepsis did not resolve. Intraoperative histopathology suggested Candida infection, and she recovered only after systemic antifungal therapy.

DISCUSSION

Debilitation conditions like tuberculosis cause weight loss and loss of intra-abdominal fat pad, which is known to precipitate SMA syndrome. However, its presentation in the early post-operative period is rare. Symptoms may vary from non-specific abdominal fullness and weight loss to features of acute bowel obstruction. CECT of whole abdomen can help in confirming the diagnosis. SMA syndrome is often not considered in differential diagnosis and can delay treatment. Medical management is the mainstay treatment option, although surgery is reserved for cases, which fail medical treatment.

CONCLUSION

High suspicion is needed to diagnose SMA syndrome in the postoperative period, which precipitates with intractable bilious vomiting. Medical management may be curative. The precipitating factor for SMA syndrome should also be addressed to improve the overall patient outcome.

Recurrent retrorectal tailgut cyst mimicking deep pelvic abscess: A diagnostic dilemma

Tailgut cysts are congenital anomalies that are rare and arise from incompletely regressed primitive hindgut. These are more commonly found in women and are usually asymptomatic. When symptoms develop, these can present with pain, infection, hemorrhage, difficulty in defecation, and rarely malignant change. We report a middle-aged married woman who presented with deep-seated perineal pain for a couple of months, which increased during defecation and sexual intercourse. Although abdominal examination was unremarkable barring deep tenderness in the hypogastrium, rectal and vaginal examinations suggested a tender pelvic swelling. An abdominal ultrasonographic examination diagnosed a cystic swelling in the pelvis extending until the Levator ani muscles. Considering her symptoms, a pelvic abscess was diagnosed and transvaginal drainage was done. Due to persistence of symptoms and recurrence after a month, she was further investigated and was diagnosed to have a presacral benign cystic tumor based on CT and MRI scans of the pelvis. The lesion was completely excised through a combined abdomino-perineal approach and histopathological report suggested a benign tailgut cyst. That a cystic presacral swelling with features of inflammation can be confused with a deep pelvic abscess is hereby highlighted in this report. An MRI scan is diagnostic of these lesions. Failure to differentiate it from a pelvic abscess may result in drainage, which may be of concern if the lesion is malignant.