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Dev S, Luitel P, Paudel S, Devkota S, Khadka L, Jha S, Dev B, Neupane N, Ghimire B. Richter supraumbilical hernia managed with invagination: a case report. Ann Med Surg (Lond) 2024; 86:3090-3093. [PMID: 38694393 PMCID: PMC11060237 DOI: 10.1097/ms9.0000000000001943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 03/02/2024] [Indexed: 05/04/2024] Open
Abstract
Introduction and importance Richter's hernia is an incarceration of the anti-mesenteric border of a segment of bowel through an abdominal wall defect. It primarily affects elderly individuals but can occur at any age, with a slightly increased incidence in females. The increase in laparoscopic and robotic-assisted procedures has led to a rise in Richter's hernias. Case presentation A 40-year-old male with a history of laparoscopic cholecystectomy and kidney transplantation presented with a 4-day history of supraumbilical swelling and abdominal pain. The swelling was irreducible and accompanied by mild tenderness, and local signs of inflammation were exhibited. Intraoperatively, a 1.5 cm hernia defect was found, with the sac containing omentum and a portion of bowel segment for which invagination with serosal closure with the Mayo double-breasting technique was done. Clinical discussion Richter's hernia presents with abdominal discomfort, bloating, nausea, and vomiting, with a notable feature being the delayed onset of symptoms due to its partial involvement of the bowel wall. Diagnosis can be achieved through a computed tomography (CT) scan or intraoperative exploration. Management of Richter hernia is contingent upon the patient's clinical condition, physical examination, and suspicion of strangulation. Conclusion Diagnosis of Richter's hernia demands higher suspicion, particularly in patients with predisposing factors like a history of minimally invasive surgery. Prompt surgical intervention is crucial for reducing mortality and enhancing prognosis, with invagination alone being adequate if ischaemia is confined and mesh placement is unnecessary.
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Affiliation(s)
- Santosh Dev
- Department of General Surgery, Tribhuvan University Teaching Hospital
| | - Prajjwol Luitel
- Maharajgunj Medical Campus, Institute of Medicine, Tribhuvan University, Kathmandu
| | - Sujan Paudel
- Maharajgunj Medical Campus, Institute of Medicine, Tribhuvan University, Kathmandu
| | - Shishir Devkota
- Department of General Surgery, Tribhuvan University Teaching Hospital
| | - Laxman Khadka
- Department of General Surgery, Tribhuvan University Teaching Hospital
| | - Sanjeev Jha
- Department of General Surgery, Tribhuvan University Teaching Hospital
| | - Barsha Dev
- Nepalgunj Medical College Teaching Hospital, Kohalpur, Nepalgunj, Nepal
| | - Nischal Neupane
- Department of General Surgery, Tribhuvan University Teaching Hospital
| | - Bikal Ghimire
- Department of General Surgery, Tribhuvan University Teaching Hospital
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2
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Khadka L, Luitel P, Paudel S, Neupane N, Awale L, Bhattarai A. Hepatic angiomyolipoma masquerading as abdominal pain: A case report. Int J Surg Case Rep 2024; 117:109516. [PMID: 38479126 PMCID: PMC10950876 DOI: 10.1016/j.ijscr.2024.109516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 03/04/2024] [Accepted: 03/07/2024] [Indexed: 03/24/2024] Open
Abstract
INTRODUCTION AND IMPORTANCE Hepatic angiomyolipoma (HAML) is a rare liver tumor composed of blood vessels, smooth muscle, and fat cells. HAML occurs across a wide age range, with symptoms including abdominal discomfort, bloating, and weight loss. Diagnosis is challenging due to varied imaging appearances, but histopathological examination supplemented by immunohistochemical analysis, particularly using HMB-45, is definitive. CASE PRESENTATION A 33-year-old man presented with a two-year history of right upper quadrant abdominal pain, occasionally relieved with analgesics but worsening over the past month and a half. Examinations revealed a soft, non-distended abdomen with a palpable liver. Laboratory tests, including viral markers and tumor markers were normal. Contrast-enhanced CT revealed a well-defined oval mass in liver segment III with heterogeneous enhancement leading to provisional diagnosis of HAML. The patient underwent a successful en bloc excision with no intraoperative or postoperative complications. CLINICAL DISCUSSION Surgical resection is recommended for symptomatic cases or inconclusive biopsies, with stringent follow-up necessary due to the potential for recurrence and association with other malignancies. CONCLUSION HAML may present with prolonged nonspecific abdominal symptoms. CT imaging aids in diagnosing cases with abundant fatty tissue. En bloc tumor excision proves safe and effective in treating symptomatic presentations.
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Affiliation(s)
- Laxman Khadka
- Department of General Surgery, Maharajgunj Medical Campus, Tribhuvan University Teaching Hospital, Nepal
| | - Prajjwol Luitel
- Maharajgunj Medical Campus, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal.
| | - Sujan Paudel
- Maharajgunj Medical Campus, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal
| | - Nischal Neupane
- Maharajgunj Medical Campus, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal
| | - Laligen Awale
- Department of General Surgery, Maharajgunj Medical Campus, Tribhuvan University Teaching Hospital, Nepal
| | - Abhishek Bhattarai
- Department of General Surgery, Maharajgunj Medical Campus, Tribhuvan University Teaching Hospital, Nepal
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Devkota S, Luitel P, Paudel S, Neupane N, Dev S, Kansakar PBS. Incidentally discovered intestinal malrotation during evaluation for blunt abdominal trauma: A case report. Int J Surg Case Rep 2024; 116:109430. [PMID: 38428056 PMCID: PMC10944091 DOI: 10.1016/j.ijscr.2024.109430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 02/17/2024] [Accepted: 02/19/2024] [Indexed: 03/03/2024] Open
Abstract
INTRODUCTION AND IMPORTANCE Intestinal malrotation is a congenital abnormality predominantly diagnosed in children, with only a few cases reported in adults. Patients may be incidentally identified during unrelated surgical procedures or postmortem examinations. It is crucial to promptly recognize this condition to prevent severe complications such as bowel ischemia and potential fatality. CASE PRESENTATION A 40-year-old male presented to the Emergency Department after a child jumped on his abdomen with complaints of acute left upper quadrant abdominal pain progressing to be generalized. Examination showed pallor, abdominal tenderness without guarding or rigidity, and intact bowel sounds. Preoperative diagnostic tools revealed intestinal malrotation confirmed during the laparotomy, prompting the performance of Ladd's procedure to address the malrotation. CLINICAL DISCUSSION Disruption in the normal embryological development of bowel is the cause of intestinal malrotation. The role of additional surgery especially in patients with asymptomatic disease related to malrotation is debated. CONCLUSION Intestinal malrotation is rare in adults and often found incidentally during evaluation for unrelated medical conditions. Timely identification and surgical intervention usually result in positive outcomes. Our case underscores the incidental discovery of malrotation during the evaluation of blunt abdominal trauma, treated with Ladd's procedure. This is particularly significant due to geographical constraints associated with the patient's rural origin, as untreated malrotation could lead to complications in future occurrences.
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Affiliation(s)
- Shishir Devkota
- Department of General Surgery, Maharajgunj Medical Campus, Tribhuvan University Teaching Hospital, Nepal
| | - Prajjwol Luitel
- Maharajgunj Medical Campus, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal.
| | - Sujan Paudel
- Maharajgunj Medical Campus, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal
| | - Nischal Neupane
- Maharajgunj Medical Campus, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal
| | - Santosh Dev
- Department of General Surgery, Maharajgunj Medical Campus, Tribhuvan University Teaching Hospital, Nepal
| | - Prasan Bir Singh Kansakar
- Department of General Surgery, Maharajgunj Medical Campus, Tribhuvan University Teaching Hospital, Nepal
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Luitel P, Yadav R, Mandal P, Adhikari N, Paudel S, Mudvari A. Maternal exposure to folate antagonists and susceptibility to congenital heart disease in offspring: A systematic review and meta-analysis. Br J Clin Pharmacol 2024. [PMID: 38369772 DOI: 10.1111/bcp.16021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 01/11/2024] [Accepted: 01/25/2024] [Indexed: 02/20/2024] Open
Abstract
AIMS The objective of this meta-analysis was to determine whether maternal exposure to folate antagonists is associated with increased rates of congenital heart disease in offspring. METHODS A comprehensive search for articles in the MEDLINE (PubMed) and EMBASE databases published up to 21 August 2023 was performed. The search strategy was not limited by study design but only for articles in the English language. RESULTS Analysis of 6 cohort studies and 5 cross-sectional studies, published between 1976 and 2020, showed significant increase in rate of congenital heart disease (odds ratio 1.55, 95% confidence interval, 1.28-1.87) when exposed to folate antagonists compared with the control. Further subgroup analysis showed the increased rate for exposure to both dihydrofolate reductase inhibitors and antiepileptic drugs separately. No differences were observed when analyses were stratified by timing of study. CONCLUSION Administration of folate antagonists within the 12-week period preceding conception and throughout the second and third months of gestation exhibited a statistically significant elevation in the susceptibility to congenital heart diseases. Notably, the protective effect of folic acid supplementation was reported in cases of congenital heart disease linked to dihydrofolate reductase inhibitors but not that associated with antiepileptic drugs.
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Affiliation(s)
- Prajjwol Luitel
- Maharajgunj Medical Campus, Tribhuvan University Institute of Medicine, Kathmandu, Nepal
| | - Rukesh Yadav
- Maharajgunj Medical Campus, Tribhuvan University Institute of Medicine, Kathmandu, Nepal
| | - Prince Mandal
- Maharajgunj Medical Campus, Tribhuvan University Institute of Medicine, Kathmandu, Nepal
| | - Niranjan Adhikari
- Maharajgunj Medical Campus, Tribhuvan University Institute of Medicine, Kathmandu, Nepal
| | - Sujan Paudel
- Maharajgunj Medical Campus, Tribhuvan University Institute of Medicine, Kathmandu, Nepal
| | - Anish Mudvari
- Department of Clinical Pharmacology, Maharajgunj Medical Campus, Tribhuvan University Institute of Medicine, Kathmandu, Nepal
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Timilsina B, Suryabanshi A, Adhikari N, Luitel P, Paudel S, Thapa B, Sharma MR. De novo subgaleal abscess complicated by spontaneous osteomyelitis and epidural abscess: a case report and review of literature. Ann Med Surg (Lond) 2023; 85:5690-5694. [PMID: 37915632 PMCID: PMC10617914 DOI: 10.1097/ms9.0000000000001285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 08/29/2023] [Indexed: 11/03/2023] Open
Abstract
Introduction and importance A subgaleal abscess is a collection of pus in a potential space between the galea aponeurotica and pericranium. De novo subgaleal abscesses are a subset of subgaleal abscesses that develop in the absence of identifiable risk factors such as head trauma or procedures. However, these have rarely been reported in the literature. Case presentation We present the case of a 65-year-old woman who presented with a headache for two and a half months, followed by swelling of the right parieto-occipital scalp. She denied any history of trauma, procedures, or anticoagulant use. A diagnosis of subgaleal abscess complicated by osteomyelitis and epidural abscess was made after obtaining a computed tomography of the head. Surgical treatment consisting of drainage, debridement, and craniectomy was performed, and the disease was successfully treated with a 6-week course of antibiotics. Clinical discussion It is uncommon to have a de novo subgaleal abscess with spontaneous osteomyelitis and an epidural abscess as concurrent complications. The symptoms can be subtle, such as chronic headaches which can lead to delayed hospital visits. Computed tomography of the head is sufficient to make a definitive diagnosis. Appropriate antibiotic therapy and surgical intervention are necessary, which may encompass incision, drainage, debridement, and occasionally a craniectomy in order to achieve full resolution. Conclusions One should be vigilant when evaluating scalp swelling for possible underlying abscesses. Prompt diagnosis and appropriate surgical treatment with adequate antibiotics are preferred treatment options for de novo subgaleal abscesses.
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Affiliation(s)
| | | | | | | | - Sujan Paudel
- Maharajgunj Medical Campus, Institute of Medicine
| | - Bikash Thapa
- Department of Neurosurgery, Tribhuvan University Teaching Hospital, Institute of Medicine, Kathmandu, Nepal
| | - Mohan R. Sharma
- Department of Neurosurgery, Tribhuvan University Teaching Hospital, Institute of Medicine, Kathmandu, Nepal
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Luitel P, Neupane N, Paudel S, Adhikari N, Timilsina B, Suryabanshi A, Gyawali P, Ojha R. Prevalence and Clinical Types of Tremor in Multiple Sclerosis and its Associated Disability: A Systematic Review. Tremor Other Hyperkinet Mov (N Y) 2023; 13:34. [PMID: 37719089 PMCID: PMC10503526 DOI: 10.5334/tohm.776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 08/26/2023] [Indexed: 09/19/2023] Open
Abstract
Objective To describe the state of literature regarding prevalence, clinical types of tremor in Multiple Sclerosis and associated disability. Background Tremor has long been recognized as an important symptom of multiple sclerosis. This can be intention and postural tremor that affects the upper limbs. Patients with multiple sclerosis who experience tremor of any severity typically retire early or lose their jobs due to disability. Methods This systematic review was performed up to September 9, 2022. Article selection was performed by searching the MEDLINE (PubMed) and EMBASE electronic bibliographic databases. The search strategy was not limited by study design but only for articles in the English language. Results A total of nine full-text articles were included in the analysis. Six studies were cross-sectional studies; one each was a prospective observational study, a case-control study, a community-based cohort. The prevalence of tremor in the multiple sclerosis (MS) population among studies ranged widely, between 12.5% and 68.9%. The presence of severe tremor ranged from 3% to 33%. Younger age was a significant predictor of tremor in two studies. The most common tremor subtype was action tremor. Upper extremities were the most common site involved in the majority of our studies, followed by head and neck. Conclusions Prevalence of tremor ranged from 12.5% to 68.9% in the MS population with severe tremor being an infrequent complication. Severity of tremor correlated with increasing disability. Upper limb action tremor was the most common with rare occurrences of resting and rubral tremor.
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Affiliation(s)
- Prajjwol Luitel
- Maharajgunj Medical Campus, Tribhuvan University Institute of Medicine, Maharajgunj 44600, Kathmandu, Nepal
| | - Nischal Neupane
- Maharajgunj Medical Campus, Tribhuvan University Institute of Medicine, Maharajgunj 44600, Kathmandu, Nepal
| | - Sujan Paudel
- Maharajgunj Medical Campus, Tribhuvan University Institute of Medicine, Maharajgunj 44600, Kathmandu, Nepal
| | - Niranjan Adhikari
- Maharajgunj Medical Campus, Tribhuvan University Institute of Medicine, Maharajgunj 44600, Kathmandu, Nepal
| | - Binita Timilsina
- Maharajgunj Medical Campus, Tribhuvan University Institute of Medicine, Maharajgunj 44600, Kathmandu, Nepal
| | - Anil Suryabanshi
- Maharajgunj Medical Campus, Tribhuvan University Institute of Medicine, Maharajgunj 44600, Kathmandu, Nepal
| | - Prakash Gyawali
- Emergency Department, Sukraraj Tropical and Infectious Disease Hospital, Teku 44600, Kathmandu, Nepal
| | - Rajeev Ojha
- Department of Neurology, Tribhuvan University Institute of Medicine, Maharajgunj 44600, Kathmandu, Nepal
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Luitel P, Upadhyay D, Neupane N, Paudel S, Gyawali P, Gajurel BP, Karn R, Rajbhandari R, Gautam N, Shrestha A, Ojha R. Guillain-Barre Syndrome following lower segment caesarean section under spinal anesthesia: A case report. Clin Case Rep 2022; 10:e6427. [PMID: 36245458 PMCID: PMC9552989 DOI: 10.1002/ccr3.6427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 09/03/2022] [Accepted: 09/23/2022] [Indexed: 11/11/2022] Open
Abstract
Symptoms of Guillain–Barre Syndrome (GBS) may be mistaken for typical puerperal changes, delaying diagnosis. Surgery and anesthesia may be triggers for GBS with an overall increase in pro‐inflammatory cytokines in the postpartum period. We report a unique case of GBS in the postpartum period who made a good recovery with supportive measures. Guillain–Barre Syndrome (GBS) symptoms may be misinterpreted as usual puerperal changes. Prompt diagnosis and management are crucial to minimize complications. We report a case wherein we managed a post‐surgical GBS with conservative agents resulting full recovery.
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Affiliation(s)
- Prajjwol Luitel
- Maharajgunj Medical CampusTribhuvan University Institute of MedicineKathmanduNepal
| | - Devansh Upadhyay
- Maharajgunj Medical CampusTribhuvan University Institute of MedicineKathmanduNepal
| | - Nischal Neupane
- Maharajgunj Medical CampusTribhuvan University Institute of MedicineKathmanduNepal
| | - Sujan Paudel
- Maharajgunj Medical CampusTribhuvan University Institute of MedicineKathmanduNepal
| | - Prashant Gyawali
- Maharajgunj Medical CampusTribhuvan University Institute of MedicineKathmanduNepal
| | | | - Ragesh Karn
- Department of NeurologyTribhuvan University Institute of MedicineKathmanduNepal
| | - Reema Rajbhandari
- Department of NeurologyTribhuvan University Institute of MedicineKathmanduNepal
| | - Niraj Gautam
- Department of NeurologyTribhuvan University Institute of MedicineKathmanduNepal
| | - Ashish Shrestha
- Department of NeurologyTribhuvan University Institute of MedicineKathmanduNepal
| | - Rajeev Ojha
- Department of NeurologyTribhuvan University Institute of MedicineKathmanduNepal
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Luitel P, Poudel B, Upadhyay D, Paudel S, Tiwari N, Gajurel BP, Karn R, Rajbhandari R, Shrestha A, Gautam N, Ojha R. Guillain-Barré syndrome following coronavirus disease vaccine: First report from Nepal. SAGE Open Med Case Rep 2022; 10:2050313X221100876. [PMID: 35646371 PMCID: PMC9130842 DOI: 10.1177/2050313x221100876] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 04/27/2022] [Indexed: 12/19/2022] Open
Abstract
ChAdOx1 nCoV-19 is an effective and well-tolerated coronavirus disease 2019 vaccine. However, rare cases of serious adverse events have been reported with it. We report a patient who did not have active or prior coronavirus disease 2019 infection, who developed Guillain-Barré syndrome 7 days following the first dose of ChAdOx1 nCoV-19 vaccination. He was treated with intravenous immunoglobulin, with stabilization of the disease. Proper monitoring and prompt reporting of such cases are required to ensure the safety of the vaccine.
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Affiliation(s)
- Prajjwol Luitel
- Tribhuvan University Institute of
Medicine, Kathmandu, Nepal
| | - Bibek Poudel
- Tribhuvan University Institute of
Medicine, Kathmandu, Nepal
| | | | - Sujan Paudel
- Tribhuvan University Institute of
Medicine, Kathmandu, Nepal
| | - Nishan Tiwari
- Tribhuvan University Institute of
Medicine, Kathmandu, Nepal
| | - Bikram Prasad Gajurel
- Department of Neurology, Tribhuvan
University Institute of Medicine, Kathmandu, Nepal
| | - Ragesh Karn
- Department of Neurology, Tribhuvan
University Institute of Medicine, Kathmandu, Nepal
| | - Reema Rajbhandari
- Department of Neurology, Tribhuvan
University Institute of Medicine, Kathmandu, Nepal
| | - Aashish Shrestha
- Department of Neurology, Tribhuvan
University Institute of Medicine, Kathmandu, Nepal
| | - Niraj Gautam
- Department of Neurology, Tribhuvan
University Institute of Medicine, Kathmandu, Nepal
| | - Rajeev Ojha
- Department of Neurology, Tribhuvan
University Institute of Medicine, Kathmandu, Nepal
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Luitel P, Neupane N, Adhikari N, Paudel S, Gajurel BP, Karn R, Rajbhandari R, Gautam N, Shrestha A, Ojha R. Paraparetic Guillain-Barre syndrome: An uncommon diagnosis of acute flaccid paralysis of the lower limbs. Clin Case Rep 2021; 9:e04767. [PMID: 34484783 PMCID: PMC8405532 DOI: 10.1002/ccr3.4767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 08/10/2021] [Accepted: 08/17/2021] [Indexed: 11/11/2022] Open
Abstract
Apart from the usual differentials of transverse myelitis and cord compression, paraparetic GBS should be considered when sudden, flaccid paralysis of the lower limbs occurs, as prompt diagnosis and management can minimize sequel and unnecessary procedures. We do report a case wherein we managed a similar situation without the use of an immunomodulatory therapy.
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Affiliation(s)
- Prajjwol Luitel
- Maharajgunj Medical CampusTribhuvan University Institute of MedicineKathmanduNepal
| | - Nischal Neupane
- Maharajgunj Medical CampusTribhuvan University Institute of MedicineKathmanduNepal
| | - Niranjan Adhikari
- Maharajgunj Medical CampusTribhuvan University Institute of MedicineKathmanduNepal
| | - Sujan Paudel
- Maharajgunj Medical CampusTribhuvan University Institute of MedicineKathmanduNepal
| | | | - Ragesh Karn
- Department of NeurologyTribhuvan University Institute of MedicineKathmanduNepal
| | - Reema Rajbhandari
- Department of NeurologyTribhuvan University Institute of MedicineKathmanduNepal
| | - Niraj Gautam
- Department of NeurologyTribhuvan University Institute of MedicineKathmanduNepal
| | - Ashish Shrestha
- Department of NeurologyTribhuvan University Institute of MedicineKathmanduNepal
| | - Rajeev Ojha
- Department of NeurologyTribhuvan University Institute of MedicineKathmanduNepal
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Luitel P, Shrestha BM, Adhikari S, Kandel BP, Lakhey PJ. Incidental finding of jejunal diverticula during laparotomy for suspected adhesive small bowel obstruction: A case report. Int J Surg Case Rep 2021; 85:106268. [PMID: 34388902 PMCID: PMC8355921 DOI: 10.1016/j.ijscr.2021.106268] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 07/31/2021] [Accepted: 08/01/2021] [Indexed: 02/08/2023] Open
Abstract
INTRODUCTION AND IMPORTANCE Jejunal diverticula are usually asymptomatic and are discovered incidentally. While rare, their complications may be life-threatening. They should be considered as differential diagnoses in undiagnosed complaints of chronic abdominal pain, malabsorption, anemia, gastrointestinal bleed and intestinal obstruction. CASE PRESENTATION A 66-year lady, known hypertensive and hypothyroidism with history of hysterectomy presented with symptoms suggestive of small bowel obstruction. Intraoperatively adhesions between loops of the small intestine, multiple diverticula with two of them impending perforation were found. Resection of 10 cm of jejunum containing diverticula with end-to-end anastomosis was performed. She had uneventful recovery and on 2 months of follow-up she was doing well. CLINICAL DISCUSSION Although diverticula can be found anywhere along the gastrointestinal tract, jejunal diverticula are rare. Most patients are asymptomatic, symptoms if present is non-specific that delay diagnosis causing patients to land up with complications. They are diagnosed incidentally on endoscopy or imaging rather than through clinical suspicion. Asymptomatic cases do not mandate treatment while symptomatic cases can be managed conservatively with surgery being reserved for those with complications. CONCLUSION Small bowel obstruction due to jejunal diverticula is a rare entity, a diagnosis of which can be confirmed only intra-operatively. So it must be borne as a differential in small bowel obstruction. Timely diagnosis and management will prevent life-threatening complications of it.
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Affiliation(s)
- Prajjwol Luitel
- Maharajgunj Medical Campus, Institute of Medicine, Kathmandu, Nepal.
| | | | - Shankar Adhikari
- Department of GI and General Surgery, Tribhuvan University Teaching Hospital, Institute of Medicine, Kathmandu, Nepal
| | - Bishnu Prasad Kandel
- Department of GI and General Surgery, Tribhuvan University Teaching Hospital, Institute of Medicine, Kathmandu, Nepal
| | - Paleswan Joshi Lakhey
- Department of GI and General Surgery, Tribhuvan University Teaching Hospital, Institute of Medicine, Kathmandu, Nepal
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Abstract
The creation of a small opening called the fusion pore is a necessary prerequisite for neurotransmitter release from synaptic vesicles. It is known that high intensity electric fields can create pores in vesicles by a process called electroporation. Due to the presence of charged phosphatidylserine (PS) molecules on the inner leaflet of the cell membrane, an electric field that is strong enough to cause electroporation of a synaptic vesicle might be present. It was shown by K. Rosenheck [K. Rosenheck. Biophys J 75, 1237-1243 (1998)] that in a planar geometry, fields sufficient to cause electroporation can occur at intermembrane separations of less than approximately 3 nm. It is frequently found, however, that the cell membrane is not planar but caves inward at the locations where a vesicle is close to it. Indentation of the cell membrane in the fusion region was modelled as a hemisphere and a theoretical study of the electric field in the vicinity of the cell membrane taking into account the screening effect of dissolved ions in the cytoplasm was performed. It was discovered that fields crossing the electroporation threshold occurred at a distance of 2 nm or less, supporting the claim that electroporation could be a possible mechanism for fusion pore formation.
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Affiliation(s)
- P Luitel
- Department of Physics, Massachusetts Institute of Technology, Cambridge, MA 02139-4307, USA
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