BackgroundPancreatic cysts are being diagnosed more frequently because of the increasing usage of imaging techniques. A pseudocyst with the major diameter of 10 cm is termed as a giant cyst. Asymptomatic pseudo-cysts up to 6 cm in diameter can be safely observed and monitored without intervention, but larger and symptomatic pseudocysts require intervention.Case presentationA 27-year-old Sri Lankan male, with history of heavy alcohol use, presented with progressive abdominal distension following an episode of acute pancreatitis. Contrast enhanced CT scan of the abdomen showed a large multilocular cystic lesion almost occupying the entire abdominal cavity and displacing the liver medially and the right dome of the diaphragm superiorly. The largest locule in the right side measured as 30 cm × 15 cm × 14 cm. Endoscopic ultrasound guided drainage of the cyst was performed. The cyst was entered into with an electrocautery-assisted cystotome and a lumen-opposing metal stent was deployed under fluoroscopic vision followed by dilatation with a 10 mm controlled radial expansion balloon. Repeat endoscopic ultrasound was done a week later due to persistence of the collection and a second stent was inserted. Then 10 French gauge × 10 cm double ended pigtails were inserted through both stents. The cysts were not visualized on subsequent Ultra sound scans. Stent removal was done after 3 weeks, leaving the pigtails insitu. The patient made an uneventful recovery.ConclusionGiant pancreatic pseudocysts are rare and earlier drainage is recommended before clinical deterioration. Some experts suggest that cystogastrostomy may not be appropriate for the treatment of giant pancreatic pseudocysts and in some instances external drainage of giant pancreatic pseudocysts may be safer than cystogastrostomy. Video-assisted pancreatic necrosectomy with internal drainage and laparoscopic cystogastrostomy were also tried with a good outcome. With our experience we suggest endoscopic guided internal drainage as a possible initial method of management of a giant pseudo cyst. However long-term follow up is needed with repeated imaging and endoscopy. In instances where the primary endoscopic internal drainage fails, surgical procedures may be required as a second line option.
BackgroundST elevation myocardial infarction is a medical emergency and the electrocardiogram is a part of the mainstay in the initial diagnosis. A variety of non-cardiac conditions have been known to mimic the electrocardiographic changes seen in acute coronary syndrome. We present a patient presenting with acute partial intestinal obstruction causing gastric distension and intestinal dilatation who also had dynamic electrocardiographic changes, mimicking anterior ST elevation myocardial infarction. Only very few cases of gastric distention and intestinal dilatation leading to acute ST segment elevation in electrocardiogram are reported so far in literature.Case presentationA fifty-six-year-old Sri Lankan male, without any modifiable risk factors for ischemic heart disease presented with acute onset nausea, vomiting, sweating, abdominal discomfort and fullness without any chest pain. On examination, he had a pulse rate of 50 beats per minute and his blood pressure was 110/50 mmHg. His abdomen was distended and the liver dullness was not detectable. Subsequent ECG showed > 2 mm ST elevations with T inversions in chest leads V1 to V3, J point elevation in leads L 11, L 111, aVF and T inversion in leads L 1 and aVL. Cardiac biomarkers were normal and 2D echo showed normal left ventricular function without any regional wall motion abnormalities. Abdominal X-ray showed a distended stomach, dilated ascending and descending colon with absent rectal air. Electrocardiographic changes reverted back to normal with the resolution of bowel obstruction.ConclusionThe mechanism of ECG changes in such a case like this is yet to be elucidated, but can be postulated to happen due to change in the position of the heart in the thoracic cavity causing change in the cardiac axis. This case emphasizes the importance of a proper history and highlights the value of auxiliary investigations such as cardiac biomarkers and echocardiogram in the diagnosis of acute coronary syndrome in a confusing situation such as this. This also illustrates the importance of early recognition of other noncardiac causes like acute gastric distention as being responsible for dynamic ECG changes. This will obviate a myriad of unnecessary investigations, interventions, costly management strategies and patient anxiety.
The pathophysiology of severe dengue is related to increased capillary permeability and plasma leakage into extracellular space. A simple, low cost risk prediction tool for plasma leakage will be useful for clinicians practicing in rural areas without imaging facilities. Study design: A prospective observational study was carried out over 12 months at the National Hospital, Sri Lanka enrolling patients with confirmed diagnosis (via NS1 antigen testing) of early dengue infection. Clinical features on admission and investigation results on D3, D5 and D7 of the illness were recorded. Evidence of plasma leakage was confirmed by ultrasonography. Results: A total of 179 patients met the inclusion criteria (males; 91, 50.8%, mean age: 31.6 years, SD ± 14.7). Sixty seven patients (67/173, 38.7%) had ultrasonographic evidence of plasma leakage. Several clinical features (severe vomiting, severe diarrhoea, abdominal pain and liver tenderness) as well as mean differences of some investigations were significantly associated with progression to plasma leakage. However, only liver tenderness on day 3 emerged as independent significant predictors of critical phase in the adjusted analysis (specificity: 93%, sensitivity: 44%). Conclusions: Having liver tenderness by day 3 of the illness is helpful to identify a subgroup of patients at risk of plasma leakage.
ObjectivesThis study aimed to assess the knowledge, attitudes and skills of non-specialist doctors on timely referral of suspicious lesions for melanoma diagnosis.ResultsOne hundred and twenty-three doctors (mean age; 30.4 years, SD ± 8.015) were enrolled. Very few (3.3%) correctly stated all four types of melanoma. Only 8.1% of the total sample had been trained to perform a total body examination for skin cancer detection and a majority (110/123) had never performed one. Almost all (95.2%) were not confident in using a dermatoscope for examination of a skin lesion. Only 17.9% of participants had discussed skin cancer/melanoma risk reduction with patients. Only 13.8% had educated at least one patient regarding skin self-examination for suspicious skin lesions. Knowledge and clinical skills regarding melanoma recognition was unsatisfactory in our sample. Urgent attention is needed to bridge the gap in knowledge and clinical skills on this topic.
Background/Aims Osteoarthritis (OA) is a common, challenging condition and is a leading cause of disability and impaired quality of life in Sri Lanka due to its ageing population and obesity pandemic. Conventional therapies for OA such as non-pharmacological measures, analgesics and surgical interventions have their own limitations. Platelet rich plasma (PRP) has been suggested as a second-line treatment by European Alliance of Associations for Rheumatology (EULAR) for early and moderate OA, which needs further evaluation to prove its efficacy and safety. This is a retrospective analysis of the effectiveness and safety of PRP injections, in a cohort of patients, attending the National Hospital of Sri Lanka for primary knee OA. Methods A total of 33 patients who had been treated with PRP injections were examined immediately prior to injection as well as 3 weeks, 3 months and 6 months later. Details of clinical variables, demographic data, and assessment of efficacy and safety were gathered by the pre-treatment form filled at the routine clinics. Pre-treatment form is comprised of inclusion and exclusion criteria, gender, biochemical investigations, radiological evidences in the knee joint, usage of previous pharmacological and non-pharmacological treatment received by the patient, weight, height and body mass index (BMI). Pain at the site of infection, stiffness, bleeding and local infection were examined as measures of safety. Pain score according to visual analogue scale and Western Ontario and McMaster Universities Osteoarthritis index (WOMAC) score were used as measures of effectiveness. Descriptive statistics was used to present demographic and clinical variables. Friedman test with Wilcoxon signed rank test for pairwise comparisons were used in the analysis of related samples of pain scores and WOMAC scores pre and post PRP therapy in order to assess effectiveness. Results Stiffness following PRP injection was experienced by 8 (24.2%) participants but none of the patients developed pain and bleeding. Median of pain score before PRP injection was 7.00 and it was reduced to 3.00 after 6 months of therapy. Median of WOMAC score before PRP injection was 54.00 and it was reduced to 30.00 after 6 months of therapy. Significant reduction of pain score (p = 0.000) as well as WOMAC score (p = 0.000) was observed. A significant gradual reduction of both pain score and WOMAC score was observed at 3 weeks, 3 months and 6 months post PRP injection (p = 0.000). Conclusion PRP injections had a good safety profile in our study. A similar trend of improvement of knee OA was observed in terms of both pain score and WOMAC score which ensures its effectiveness. However, with a guidance of these data in Sri Lankan patients, a randomized double blinded clinical trial is recommended. Disclosure R.M. Wickramarachchi: None. S. Janagan: None. W. Udeshika: None. G. Chandana: None. Y. Udara: None. S. Fernando: None.
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