A prospective and retrospective study of actinomycosis in last five years at Manipal Teaching Hospital, Pokhara, Nepal

OBJECTIVE

The study was carried out to determine the clinical and morphological presentation of actinomycosis and its association with malignancy and other opportunistic infections.

MATERIAL AND METHODS

A prospective and retrospective study of cases was done from January 2001 to December 2006 (5 years) in the department of pathology.

RESULT

Total 19 cases of actinomycosis were found during this period. Patients presented with discharging sinus and non-healing superficial abscess. Out of 19 cases, three cases were associated with malignancy, two cases were associated with aspergillosis while one case was clinically misdiagnosed as malignancy. All cases were diagnosed pathologically except a case of maxillary sinusitis which was initially suspected as fungal sinusitis by CT scan. Since actinomycosis is often misdiagnosed it is important to know the clinical presentation and morphological features of actinomycosis for correct management.

CONCLUSION

The clinical features and histopathological findings of actinomycosis are important to understand for its correct diagnosis and better management of patient.

Primary malignant melanoma of vagina--a case report with review of literature

Primary vaginal malignant melanoma is a very rare tumor with less than 300 cases reported to date. We describe a case of primary vaginal melanoma and review the literature. A 60 years postmenopausal female patient presented with painless mass coming out of the vagina with occasional bleeding for last 2-3 weeks. On vaginal examination there was a firm polypoidal growth of size 7 cm attached to the right lateral wall of vagina and coming out of the introitus. Histopathology of the mass showed features of malignant melanoma. Wide local excision was done and adjuvant therapy was given. However patient came back after three months with widespread metastasis and expired 6 months after the initial diagnosis. Vaginal melanoma is a very aggressive tumor and the overall prognosis is very poor despite the treatment modality.

Primary Malignant Melanoma of Vagina – A Case Report with Review of Literature

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A comparative study of intratumoral chemotherapy in advanced childhood common solid tumors

BACKGROUND

Advanced and inoperable solid tumors in children are great killer despite aggressive multimodality treatment. Intravenous chemotherapy, due to high dose of drug given systemically, at times leads to abandonment of therapy due to systemic toxicities. To overcome this problem lots of studies are going on to explore alternative modes of giving anticancer drugs so as to decrease the systemic toxicities of the drugs and increase their therapeutic index at the same time.

AIM

The study was conducted to know the results of anterior intratumoral chemotherapy and its comparison to anterior intravenous chemotherapy.

MATERIALS AND METHODS

Forty patients of advanced inoperable solid tumors in children (Wilms' tumor and neuroblastoma) between 2000-2004 were randomly allocated to two groups. Group A (20 patients) was given intratumoral chemotherapy while Group B (20 patients) was given intravenous chemotherapy. Both the groups were compared in terms of reduction in size and volume, resectability of tumor, histopathological changes and side-effects of chemotherapeutic drugs. The Institute's ethics committee approved this study.

RESULTS

Males were predominant in both type of cases (Wilms' tumor and neuroblastoma) in both the groups (Group A and Group B). Mean age in the study was 3.27 years. All cases in Group A had Stage III disease except three cases which had Stage IV disease (one case of Wilms' tumor and two cases of neuroblastoma) while in Group B only two cases had Stage IV disease (one case of Wilms' tumor and one case of neuroblastoma). Intratumoral chemotherapy was found to be superior over intravenous chemotherapy in terms of reduction of size and volume (63% in Group A vs. 22% in Group B). The resectability was 70% in the intratumoral group in comparison to 40% in the intravenous group. The overall good histopathological response was 71% in Group A as opposed to 0% in Group B. Moreover, the incidence and severity of side-effects of chemotherapy and morbidity was less in intratumoral chemotherapy. Mortality was also low in Group A (5%) in comparison to Group B (20%).

CONCLUSION

In this study intratumoral chemotherapy was found to be superior over intravenous chemotherapy in terms of better and early tumor regression, minimal side-effects, better tumor resectability and well response on histopathological criteria. This study is still going on at our center where different drug combinations, different drug doses, their toxicities, their mechanisms of action, their serum levels and long-term results of intratumoral mode of chemotherapy are to be evaluated thoroughly in future.

Estrogen and progesterone receptor status in breast cancer: Effect of oral contraceptive pills and hormone replacement therapy

BACKGROUND

Higher incidence of hormone receptor positive breast cancer (BC) in White women compared to Blacks and Asians is attributed to different inherent biology. Many of our patients have estrogen receptor (ER) and progesterone receptor (PR) negative tumors. We tried to explore if this is related to low frequency of oral contraceptive pills (OCP) and hormone replacement therapy (HRT) intake.

SETTING

Breast Unit, Department of Surgical Oncology, Tertiary Care Hospital, India.

METHODS

Records of female BC patients classified as 'Users' of OCP/HRT for minimum of 1 year and age, stage, histopathology matched 'Non-users' were reviewed retrospectively from January 1990 to October 2006.

RESULTS

Analysis of 150 evaluable 'Users' (58/122 premenopausal, 92/178 postmenopausal) and 150 matched 'Non-users' revealed 128 (42.67%) patients had ER and PR-negative, 157 (52.33%) ER and PR-positive, 12(4%) ER-positive/PR-negative, 3(1%) ER-negative/PR-positive tumor. Significantly more ER-positive tumor was found in both premenopausal [62.07% versus 39.06%, p=0.0184, odd's ratio (OR) 2.5527 and 95% confidence interval (CI) 1.2297-5.2993] and postmenopausal (63.04% versus 40.7%, p=0.0046, OR 2.4857 and 95% CI 1.3593-4.5455) 'Users' compared to 'Non-users', respectively. Grade III tumors were significantly less in premenopausal (p=0.0041) and postmenopausal (p=0.0012) 'Users'.

CONCLUSIONS

These observations suggest that a low incidence of hormone receptor positivity in our patients could be partly due to low prevalence of OCP/HRT intake.

Leiomyosarcoma of kidney: a case report with long term result after radiotherapy and chemotherapy

Leiomyosarcoma of the kidney is a rare entity with poor prognosis. Among renal sarcomas, it is the most common histologic subtype amounting to 50-60% of all cases. The tumors usually arise from either the renal capsule or smooth muscle tissue in the renal pelvic wall. We describe a case of renal leiomyosarcoma that presented with history of left flank pain. Physical examination was normal. Abdominal ultrasound showed a solid lesion of 38 x 36 mm arising from the left kidney. Intravenous urography showed cut off of both major and minor calyces of the left kidney from its pelvis with a normal right kidney. Exploratory laparotomy revealed a well-encapsulated mass confined to the renal parenchyma for which radical nephrectomy was performed. Histopathology showed a Grade I leiomyosarcoma arising from the renal capsule. Adjuvant chemotherapy and sandwich radiotherapy was given and he is disease free after six and half years of follow up. The rarity of this disease, its severity and poor prognosis, uncommon form of presentation, resulting delay in diagnosis and difficulty in management is highlighted and reported.

Bacteriological profile of community acquired acute bacterial meningitis: a ten-year retrospective study in a tertiary neurocare centre in South India

PURPOSE

Ten years retrospective study to evaluate the bacteriological spectrum of community acquired acute bacterial meningitis (CAABM).

METHODS

Cerebrospinal fluid (CSF) samples from 385 clinically suspected cases of pyogenic meningitis were processed for cell counts, cytospin Gram stain, culture, antigen detection by latex agglutination (LAT) and antibiotic susceptibility test. Eighteen of these CSF samples were also subjected to a polymerase chain reaction (PCR) assay for detection of pneumococcal DNA.

RESULTS

The etiological agent could be identified in 284 (73.8%) of the total 385 cases by culture and/or smear and /or LAT. Streptococcus pneumoniae was the predominant pathogen accounting for 238 (61.8%) cases. Haemophilus influenzae and Neisseria meningitidis accounted for 7 (1.8%) and 4 (1%) cases respectively. Other gram negative bacilli, Streptococcus spp. and Staphylococcus aureus were isolated from 19 (4.9%), 9 (2.3%) and 7 (1.8%) cases respectively.

CONCLUSIONS

Streptococcus pneumoniae remains the major aetiological agent of CAABM both in adults and children in our set-up. No penicillin resistance was detected among the isolates. Further research should focus on preventable aspects of CAABM, especially pneumococcal vaccines, to help reduce the disease burden.

Fatal Group A Streptococcal meningitis in an adult

Despite the recent resurgence in reports of invasive Group A Streptococcal (GAS) infections worldwide, it remains a rare cause of pyogenic meningitis both in children and adults. We report a case of fatal GAS meningitis in a healthy adult emphasizing the need for clinicians to be aware of its fulminant course, prompting early diagnosis and treatment. There is also a need to consider postexposure chemoprophylaxis in close contacts of such cases.

To Bite the Bullet of Early Graft Nephrectomy: A Case Report

Isolated renal allograft mucormycosis is rare. Only 8 cases have been reported to date, with patient survival in only 3. We recently encountered a case. The presentation was fever and graft dysfunction, which were unresponsive to extended antibiotic treatment and supportive care. It was only after three graft biopsies that mucormycosis was diagnosed and amphotericin B started. Urgent graft nephrectomy was performed, but the patient died of septicemia. In retrospect, we believe that early institution of amphotericin B and graft nephrectomy are needed for patient salvage in this difficult clinical situation.

Dose dependent effect of ricin on DNA damage and antioxidant enzymes in mice

Ricin a glycoprotein from the Ricinus communis seeds, is known to have diverse toxic effects on cells of different visceral organs. We have studied the effect of ricin (0.5, 1.0 and 2.0 LD50) on various oxidative stress markers at 1, 3 and 7 day post exposure following i.p. administration in Swiss albino male mice. Results of this study revealed that ricin induces generation of reactive species, lipidperoxidation, DNA fragmentation and depletion of GSH. Activity of antioxidant cascade related enzyme like superoxide dismutase (SOD), glutathione peroxidase (GPx) decreased, while glutathione reductase (GR) and catalase activity increased. Superoxide dismutase and glutathione peroxidase activity was decreased significantly in liver, spleen and kidney. The decrease was more prominent on 7 day of post exposure in all the exposed doses. A significant increase in the activities of catalase was observed in plasma, liver, spleen and kidney on 7 day following ricin exposure. Glutathione reductase increased significantly as early as 24 h following 1.0 LD50 dose. Lipid peroxidation increased and non protein sulfhydryl content decreased in all the tissues at different time intervals. Total antioxidant status was reduced as early as 1 day post exposure. Nearly two fold increase was observed in DNA fragmentation following 0.5 LD50 dose of ricin on 1 day post exposure. DNA diffusion assay also indicated an early damage to DNA due to ROS. An early change in DNA fragmentation, DNA diffusion, and total antioxidant status and in the activity of various enzymes indicates that ricin produce oxidative stress by generation of reactive oxygen species as early as 24 h at a minimum dose of 0.5 LD50. Probably this is the first study which indicate that ricin induced oxidative stress at a minimum dose of 0.5 LD50.

Preceding infections and anti-ganglioside antibodies in patients with Guillain-Barré syndrome: a single centre prospective case-control study

Preceding infections and anti-ganglioside antibodies were assessed among 80 Guillain-Barré syndrome (GBS) patients and 125 controls. Previous infections were more frequent among GBS patients than among controls (p <0.0001), and had a significant association with axonal subtype compared with acute inflammatory demyelinating polyneuropathy (AIDP) (29/46 vs. 10/34 patients; p <0.05). Campylobacter jejuni (26%) was the most common preceding infection among GBS patients, followed by Mycoplasma pneumoniae (15%). Anti-ganglioside antibodies were detected more frequently among GBS patients than among controls (65/80 vs. 13/125; p <0.001), and a higher proportion of axonal cases had these antibodies than did AIDP patients (43/46 vs. 22/34; p <0.01).

Viral oncoproteins target the DNA methyltransferases

Small DNA tumour viruses have evolved a number of mechanisms to drive nondividing cells into S phase. Virally encoded oncoproteins such as adenovirus E1A and human papillomavirus (HPV) E7 can bind an array of cellular proteins to override proliferation arrest. The DNA methyltransferase Dnmt1 is the major mammalian enzyme responsible for maintaining CpG methylation patterns in the cell following replication. One of the hallmarks of tumour cells is disrupted DNA methylation patterns, highlighting the importance of the proper regulation of DNA methyltransferases in normal cell proliferation. Here, we show that adenovirus 5 E1A and HPV-16 E7 associate in vitro and in vivo with the DNA methyltransferase Dnmt1. Consistent with this interaction, we find that E1A and E7 can purify DNA methyltransferase activity from nuclear extracts. These associations are direct and mediated by the extreme N-terminus of E1A and the CR3 zinc-finger domain of E7. Furthermore, we find that a point mutant at leucine 20 of E1A, a residue known to be critical for its transformation functions, is unable to bind Dnmt1 and DNA methyltransferase activity. Finally, both E1A and E7 can stimulate the methyltransferase activity of Dnmt1 in vitro. Our results provide the first indication that viral oncoproteins bind and regulate Dnmt1 enzymatic activity. These observations open up the possibility that this association may be used to control cellular proliferation pathways and suggest a new mechanism by which small DNA tumour viruses can steer cells through the cell cycle.

Nasal glioma: a case report

Here we describe a rare case of nasal glioma in a 14 year old boy who presented with history of right nasal obstruction and nasal discharge since 6 months. On examination a pale mass was seen filling the right nasal cavity and extending down in the oropharynx. Clinical impression was antrochoanal polyp. Excision of the mass was carried out and sent for histopathology which showed presence of glial tissue and the diagnosis was made as nasal glioma.

Development of passive haemagglutination (PHA) and haemagglutination inhibition (HAI) technique for potency estimation of Cobra Antisnake Venom Serum (ASVS)

Antibodies against snake venom or antivenom potency are assayed quantitatively by in-vivo neutralization test in mice, which requires large number of laboratory animals. In potency assays of biological substances such as antivenoms, it is highly desirable to avoid suffering and death of animals by substituting in-vivo method with in-vitro methods, provided such methods measure life-saving capability with precision similar to that of in-vivo method. The in-vitro tests determine the neutralizing power of antivenom by permitting the evaluation of a particular biological activity of the venom and its neutralization after mixing the venom with the antivenom [Theakston RDG, Reid HA. Development of simple standard assay procedures for the characterization of snake venom. Bull WHO 1983;61:949-956; Gutierrez JM, Rojas G, Lomonte B, Gene JA, Chaves F, Alvarado J, et al. Standardizing of assays for testing the neutralizing ability of antivenoms. Toxicon 1990;28:1127-1129; Theakston R.D.G. Comments on letter of Gutierrez et al. on standardization of assays for testing the neutralizing ability of antivenoms. Toxicon 1990;28:1131-1132; Harvey AL, Barfaraz A, Thomson E, Faiz A, Preston S, Harris JB. Screening of snake venom for neurotoxic and myotoxic effects using simple in-vitro preparation from rodents and chicks. Toxicon 1994;32:257-265; World Health Organization Progress in characterization of venom and standardization of anti-venoms. Geneva: WHO offset publication; 1981. p. 58.]. Hence, the ideal requirements for an assay in detecting venom and venom antibody include high level of sensitivity, specificity (ability to differentiate between venom and venom antibody produced by closely related species of snakes), reproducibility and simplicity. A new in-vitro procedure for quantitative analysis of potency of ASVS by passive haemagglutination (PHA) and haemagglutination inhibition (HAI) has been explored. The methods described are simple, rapid, economical, reproducible and useful in replacing the more expensive in-vivo neutralization assays. Moreover, it also eliminates the use of laboratory animals.

Recurrence of carcinoma cervix in the scar of previous cesarean section: a case report

Although rare, reports of carcinoma cervix recurring in abdominal incision, episiotomy scars, laparoscopic port sites, and drain sites are available. However, recurrence in the scar of a previous cesarean section (CS) is unreported. A 49-year-old female with a diagnosis of keratinizing squamous cell carcinoma (SCC) of cervix, stage IIB, was treated by radical radiotherapy. She had undergone CS, through midline abdominal incision, for three previous deliveries. Twenty months later, she presented with a nodule of size 2.5 x 2 cm(2) on the 26-year-old abdominal CS scar. Infiltration of the skin and extension into the deeper structures of the abdominal wall was present in an area of 5 x 4 cm(2). There was no evidence of disease on the cervix. A fine-needle aspiration cytologic examination from the nodule revealed keratinizing SCC. Ultrasonography and computerized tomography scan revealed a mass lesion along the abdominal CS scar with subcutaneous nodule and peritoneal extension. Multiple metastatic lesions were present in the liver. She was treated with chemotherapy and radiotherapy. The patient has lived for more than 12.5 months. The first report of recurrence of carcinoma cervix in a CS scar is presented. Literature on surgical scar recurrence in carcinoma cervix is reviewed.

Effect of Prevailing Local Treatment Options of Breast Cancer on Survival Outside Controlled Clinical Trials: Experience of a Specialist Breast Unit in North India

BACKGROUND

This study aimed at analyzing different treatments of breast cancer (BC) prevalent in the region, their effect on patients' survival, and discusses the most suitable method within available resources.

METHODS

The study was set up at a tertiary care hospital in north India. We retrospectively reviewed data of 473 female BC patients who attended the departments of Surgical Oncology and Radiotherapy from January 1997 to December 1999. Patients with cTNM stage IV and inoperable stage III were included; those who defaulted or were lost to follow-up were excluded. Out of 473 patients, 372 were selected. The selected patients were divided into groups on the basis of place and type of local treatment they received: (1) local excision only, (2) standard breast conservation therapy (BCT), (3) total mastectomy (TM) + axillary lymph node dissection + radiotherapy (RT), and (4) modified radical mastectomy (MRM) + RT. Data regarding recurrence and survival were analyzed in December 2005. Minimum follow-up was 6 years.

RESULTS

Overall recurrence rates were significantly higher in patients operated elsewhere (P <0.0001). Of 194 operated at our Breast Unit, 25 (14.6%) of 171 MRM patients and none of 23 BCT had recurrence. Of 178 patients operated elsewhere, 44 (100%), 6 (42.9%), 41 (41%), and 8 (40%) developed recurrence in groups 1, 2, 3, and 4 respectively. Overall survival was significantly better in patients with MRM at our unit versus TM outside (93.6% vs. 80%).

CONCLUSIONS

Several types of treatment from improper local excision alone, BCT, TM, to a carefully done MRM are prevalent here. Properly done, MRM yields significant local control with survival benefit and appears to remain the gold standard in management of our BC patients.

Pre-operative assessment of K-nail length in fracture shaft of femur

INTRODUCTION

Internal fixation of diaphyseal fracture of shaft of femur in an adult by Kuntscher nail is the most common operative method of treatment in Nepal where operative facilities for the same exist. Since the complete range of K-nail sizes and length are not available in most operation theatres in Nepal, most orthopaedic surgeons assess the size and length of the K-nail pre-operatively by various methods and keep one size above and below the assessed length for the planned surgery.

MATERIALS AND METHODS

The following measurements were taken in five hundred people involved in the study: Measurement No. 1: Tip of the greater trochanter to lateral knee joint line minus 2 cm. Measurement No. 2: Tip of the olecranon process to the tip of little finger, and Measurement No. 3: Tip of the greater trochanter to the upper pole of patella. An average of all three lengths were analysed to see if there were any differences in their mean lengths.

RESULTS

Analysis showed that there were significant differences between the mean lengths measured by the three different methods. The average length of measurement no: 2 was 3 cm longer than the average length of measurement no: 1, which is the reference pre-operative length of K.nail.

CONCLUSION

However, in practice since measurement no:2 is more convenient to perform and can also be used when the patient has sustained bilateral fractures of femur, an accurate pre-operative K-nail length assessment can be done by subtracting 3 cm from measurement no:2, i.e. the tip of the olecranon process to the tip of the little finger.

5-Fluorouracil induces defects in platelet function

Platelet factor-3 (PF(3)) availability and platelet aggregation to ADP (4 micromol/l) and adrenaline (1.2 micromol/l) were evaluated in patients being treated with 5-fluorouracil (5-FU) for gastrointestinal malignancy. It produced a significant reduction in platelet aggregation and platelet factor-3 (PF(3)) availability ( P < 0.001) without being associated with thrombocytopenia. The changes in platelet aggregation occurred during the first week of chemotherapy and continued with subsequent courses. This acquired abnormality may be responsible for a haemorrhagic diathesis even without obvious thrombocytopenia. Study of platelet function is important and may be considered to assess the haematological toxicity in patients being treated with systemic 5-FU therapy.

Verruciform xanthoma of the oral mucosa

Verruciform xanthoma is a rather rare lesion that is mostly confined to the oral mucosa. The clinical picture may vary considerably. The diagnosis is based on the presence of numerous xanthoma cells in the connective tissue papillae. A case of verruciform xanthoma on the gingiva in relation to lower right posterior region in a 43-year-old man is presented. The findings reported in the literature are also discussed.

Surveillance of bacteriological quality of natural water resources in rural areas around Kasauli Town, Distt. Solan, Himachal Pradesh

A study was conducted to find out the bacteriological quality of water during the monsoon season in local areas around Kasauli Town, and to evaluate the management of water resources in rural areas. The water samples were collected from bowries and hand pumps. As there is no municipal water supply in majority of these areas, the local residents depends mainly on these natural resources without any treatment of water. All the 14 surface water samples collected from bowries were found bacteriologically polluted with total coliform count ranging from 35-1800+. The main contaminants isolated were atypical thermotolerant E. coli, Pseudomonas fluorescence, Enterobacter cloacae, Aeromonas liquifaciens, Citrobacter freundii and Pseudomonas pseudomaleii. Among seven hand pump samples, two were found to have Coliform count 80 and 250 respectively. These two water samples were found contaminated with Citrobacter freundii and E. coli &Aeromonas liquefaciens respectively. These bacteriological contaminations appear to be both from vegetative & human or animal excreta sources. The study therefore suggested that the water from these natural resources requires treatment either by boiling or chlorination before human consumption to avoid any outbreak.

Interaction between the Water Soluble Poly{1,4-phenylene-[9,9-bis(4-phenoxy butylsulfonate)]fluorene-2,7-diyl} Copolymer and Ionic Surfactants Followed by Spectroscopic and Conductivity Measurements

The interaction has been studied in aqueous solutions between a negatively charged conjugated polyelectrolyte poly{1,4-phenylene-[9,9-bis(4-phenoxybutylsulfonate)]fluorene-2,7-diyl} copolymer (PBS-PFP) and several cationic tetraalkylammonium surfactants with different structures (alkyl chain length, counterion, or double alkyl chain), with tetramethylammonium cations and with the anionic surfactant sodium dodecyl sulfate (SDS) by electronic absorption and emission spectroscopy and by conductivity measurements. The results are compared with those previously obtained on the interaction of the same polymer with the nonionic surfactant C12E5. The nature of the electrostatic or hydrophobic polymer-surfactant interactions leads to very different behavior. The polymer induces the aggregation with the cationic surfactants at concentrations well below the critical micelle concentration, while this is inhibited with the anionic SDS, as demonstrated from conductivity measurements. The interaction with cationic surfactants only shows a small dependence on alkyl chain length or counterion and is suggested to be dominated by electrostatic interactions. In contrast to previous studies with the nonionic C12E5, both the cationic and the anionic surfactants quench the PBS-PFP emission intensity, leading also to a decrease in the polymer emission lifetime. However, the interaction with these cationic surfactants leads to the appearance of a new emission band (approximately 525 nm), which may be due to energy hopping to defect sites due to the increase of PBS-PFP interchain interaction favored by charge neutralization of the anionic polymer by cationic surfactant and by hydrophobic interactions involving the surfactant alkyl chains, since the same green band is not observed by adding either tetramethylammonium hydroxide or chloride. This effect suggests that the cationic surfactants are changing the nature of PBS-PFP aggregates. The nature of the polymer and surfactant interactions can, thus, be used to control the spectroscopic and conductivity properties of the polymer, which may have implications in its applications.

Accuracy of ultrasonography in evaluation of level and cause of biliary obstruction: a prospective study

AIM

To find out the accuracy of ultrasound in evaluation of level and cause of biliary obstruction.

MATERIALS AND METHODS

Forty-five patients (26 to 86 years of age) with suspected biliary obstruction underwent Ultrasonography followed by Direct Cholangiograms (Percutaneous Transhepatic Cholangiography / Endoscopic Retrograde Cholangiography). The levels of biliary obstructions were grouped as hilar, suprapancreatic and intrapancreatic. Similarly the causes were grouped as malignant and benign. Diagnosis was confirmed either at surgery or histopathologically (USG-guided FNAC or ERC-biopsy).

RESULTS

Ultrasonography accurately identified the level of obstruction in 89 %( hilar), 91% (suprapancreatic) and 87% ( intrapancreatic) cases. Malignancy was found in 33 patients and remaining 12 had benign diseases. USG accurately identified malignant and benign causes in 91% and 84% cases respectively. Findings were found to be statistically significant (p-value =< 0.05 at 95%confidence interval).

CONCLUSION

This study showed that USG has high accuracy in identifying the level and cause of biliary obstruction. Considering cost, availability and patient friendly nature, Ultrasound should be the first imaging modality of choice in evaluation of biliary obstruction.