Spontaneous choledochoduodenal fistulas (CDFs) are rare. The most common aetiology is penetrating duodenal ulcers, observed in 80% of cases. Even in areas where acid peptic disease is common, tuberculosis should be considered as a cause, especially in developing countries like India, where tuberculosis is common. The management of CDF due to acid peptic disease is predominantly surgical while healing of tuberculous CDF has been reported with antitubercular treatment. A preoperative diagnosis of tuberculous CDF by endoscopic biopsy from the duodenal ulcer or image guided fine needle aspiration if abdominal lymph nodes are present can eliminate the need for surgery and achieve a cure with antitubercular treatment. The CDF in this case was due to caseation of periduodenal lymph nodes rupturing into the duodenum and the bile duct.
Background: Laparotomy forms an important subset of general surgical operations. This study aimed at collecting the baseline information on postoperative analgesia, to detect deficiencies in current management of postoperative pain and to aid as a reference for future endeavours aimed at improving pain management following abdominal surgeries.Methods: It was conducted as a prospective descriptive study in patients undergoing elective laparotomies in the Department of General Surgery of a tertiary care institute, for two years. The patterns of prescription and administration of analgesic drugs for postoperative pain after abdominal surgery, incidence and severity of postoperative pain, adverse effects of drugs and patient satisfaction were assessed.Results: A total of 289 elective laparotomies were performed. Combinations of Non-steroidal anti-inflammatory drugs (NSAID) with opioids, epidural analgesia (EA) with supplemental intramuscular ketorolac and PCEA (Patient controlled EA) provided effective pain relief with high satisfaction score (3/4) and were associated with low sedation (1/3) and the least side effects. Patients receiving NSAIDs had higher pain score with lesser satisfaction score and lower sedation score. IV-PCA with morphine provided effective pain relief with high satisfaction score (3/4), with least side effects, but patients had high sedation score (2/3). Around 55 (55/289; 19.03%) patients experienced postoperative nausea and vomiting, which responded to antiemetic treatment.Conclusions: A combination of NSAIDs with opioids provided effective pain relief, high satisfaction with less sedation and least side effects. Epidural analgesia with supplemental intramuscular ketorolac and PCEA also provided effective pain relief with high satisfaction and less sedation with least side effects.
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