Passing blood in stools – A rare disease

Mr. B______, a 50 year old patient from Saudi Arabia came to me with bleeding while passing stools (also read this interesting case ) since childhood. He was often treated for piles in his country but there was no relief. Ultimately being frustrated with his disease, he came to India. He was skinny and pale. I examined his anal canal but did not see any plies. There appeared some mass in rectum. I posted him for colonoscopy. Almost whole of his colon from rectum to cecum was involved with multiple small grape like growths called polyps. I biopsied few of them and they came benign. The diagnosis of Multiple colonic polyposis  was established.  There was no one else is his family who had similar complaints. I discussed with him about the disease and the treatment. I proposed to him complete removal of his colon including rectum (Total proctocolectomy) as these polyps can become cancerous. His immediate concern was will he live a normal life after the surgery? I assured him that life will be not normal but much better. He will get rid of his bleeding and anemia. He will however have more frequency of stools and they will be more liquid then normal. I discussed with him about temporary ileostomy and assured him that he will eventually pass stools from his anal canal. The surgery was smooth. It took me about 6 hours to operate him.I removed his whole of colon including his rectum as it was diseased using modern ultrasonic energy device so that there was very limited blood loss.I removed his whole of colon including his rectum as it was diseased using modern ultrasonic energy device so that there was very limited and was now connected to his anal canal. The joints were made using the modern staplers. I removed his whole of colon including his rectum as it was diseased using modern ultrasonic energy device so that there was very limited blood loss.terminal part of small intestine was modified to make a reservoir (J-pouch) for his stools and was now connected to his anal canal. The joints were made using the modern staplers. In such major surgeries there is always a risk of leakage from this new joint. Hence, in order to protect this joint (anastomosis), I had to divert his stools. This will allow the joint to heal nicely without getting contaminated and infected as if this happens then there is a risk to his life. Hence, I performed a diverting ileostomy for some time till he recovers. This means he will pass stools thro a small hole on his tummy into a bag. He recovered well. After few weeks I carried out radiological test and colonoscopy to ensure that the new reservoir and the joint had healed properly. I took his for his second surgery in which I had to simply close his ileostomy. He started passing stools from below about 5 – 7 times daily. He had good sensation & control over his stools and and there was no urgency. He happily returned to his home in Saudi Arabia.

Testicle Fixation

What is it?

From what you tell us and from what we have found, it looks as if your child's testis is twisting round (undergoing torsion). The twisting nips the artery and veins (the pipes that give and drain blood respectively) of the testis and slows down or stops completely the blood flow to it. This gives pain and swelling of the testis.

The testis may die if it is not operated on. In fact, the whole testis may not be twisted, just a small tag on the testis can give the same picture.

Sometimes infection around the testis mimics a twist or torsion. However it is safer for your child to have an operation than to risk loss of the testis.

The operation

Your child will have a general anaesthetic, and will be asleep for the whole operation.

After your child goes to sleep with the anaesthetic, a cut is made in the scrotum. Dr. B C Shah has a look at the testis through the opening. If it is twisted, he untwists it. He fixes it with stitches under the skin so that it cannot twist again. He does the same to the other testis, so that this one will not twist at a later date.

If the testis is already dead, it is best to take it out and it will be sent to the laboratory to be examined under a microscope. The other testis should be enough for all your son's needs in the future. If Dr. B C Shah finds something else instead, he will deal with that as needed. He will let you know the result of examination and the test.

Usually you can take your child home one or two days after the operation.

Any alternatives?

If you leave things as they are, the testis is very likely to die. The same can happen to the other side, leading to serious hormone problems.

Special ultrasound tests can be helpful, but an operation is the only way of being certain. Massaging and trying to untwist the testis through the skin rarely works and can offer some comfort but there is a very high chance that the testis will twist again soon. Therefore, an operation is the only reliable and definitive solution.

Before the operation

Your son will be welcomed to the ward by the nurses or the receptionist. He will have his hospital details checked. He will be put to bed in a gown. He will have some basic tests done to make sure that he is well prepared and that he can have the operation as safely as possible.

You will be asked to hand in any medicines or drugs he may be taking so that his drug treatment in hospital will be correct. Please tell Dr. B C Shah of any allergies to drugs or dressings.

Your son will be seen by Dr. B C Shah who will examine him. You and your child will have the operation explained to you and you will be asked to fill in an operation consent form.

Before you sign the consent form giving permission for the operation to go ahead, make sure that you fully understand all the information that was given to you regarding your child’s health, the possible and proposed treatments and any potential risks. Feel free to ask more questions if things are not entirely clear.

The operation site will be marked with a skin pencil. Your son will be seen by Dr. B C Shah who will be doing the operation. He will check that all the necessary preparations have been made.

After – in hospital

Your child will be sleepy after the operation and is likely to sleep for an hour or more afterwards.

The drugs given for a general anaesthetic will make your child clumsy, slow and forgetful for about 24 hours. This happens even if your child feels quite all right. The nurses will support you to help him with everything he needs until he feels better.

Your child will probably not notice any significant pains. If necessary he can take a painkiller by mouth, such as paracetamol in a liquid form. By the end of one week the wound should be virtually pain-free.

Your child will be able to drink again two to three hours after the operation. He should be able to eat normally the next day. There will be dissolvable stitches in the skin. They slip out after 7 to 10 days.

The wound will have a cellulose dressing rather like nail varnish. There may be some swelling of the surrounding skin which improves in two to three days. This can happen and you and your child should not worry about it.

After 7 to 10 days, slight crusts on the wound will fall off. The cellulose varnish will peel off. Occasionally minor matchhead sized blebs (blisters) form on the wound line. These settle down after discharging a blob of yellow fluid for a day or so.

If stitches are still there after 10 days, phone Dr. B C Shah because they may have to be removed. Do not try to remove them yourself.

Your child can wash but try to keep the wound area dry until the stitches are out. Baths or showers with ordinary soap and water are all right. Salted water is not necessary.

You will be given an appointment to bring your child to the outpatient department, after leaving hospital for a check up.

Some hospitals arrange a check-up about one month after leaving hospital. By this time, the results of the laboratory examination of the removed testis (if this was the case) will be ready. Others leave check-ups to the general practitioner.

After – at home

Your child may need frequent sleeps for a day or two. Although it is usually difficult to limit what he does, try to help your child avoid any excess physical activity for four to six weeks after the operation.

You need to make sure that he is careful and doesn’t aggravate the wound. This can be very painful, cause bleeding and, sometimes, an infection.

If your child goes to school he can return to lessons after about 10 days. He can restart any sport after about four to six weeks.

Possible complications

As with any operation under general anaesthetic, there is a very small risk of complications related to the heart and the lungs.

If the testis is twisted and very painful, the risk from the anaesthetic is slightly higher when the operation is done as an emergency. The tests that your child will have before the operation will make sure that he can have the operation in the safest possible way and will bring the risk for such complications very close to zero.

If you think that all is not well, please let Dr. B C Shah know. There is often some swelling and even some redness around the wound. These usually settle in three or four days.

Bleeding is very rarely a problem and is usually stopped with some extra pressure on the wound area. Extremely rarely, another operation is needed to stop the bleeding. Infection in the wound area is a rare problem and settles down with antibiotics in a week or two.

There is also a chance that your child can experience some swelling of the testis. This also gets settled by taking antibiotics for a week or two.

There is a chance that the testis will stay alive after the operation but will have some shrinkage (atrophy). This can happen because the blood supply to the testis was affected for a long time while it was twisted or because after the operation the blood flow did not return to normal.

If the testis in fact dies despite the operation, the wound will get quite painful and swollen. Phone Dr. B C Shah for advice if you are in doubt. This situation will require prompt medical attention and another operation might be needed to deal with the problem.

Another rare complication that can happen during this operation is damage to the structures that carry the sperm from the testis. This can have an affect on your child’s fertility in the future (his ability to father children) since one of his testes will not contribute sperm. You should discuss the possibility of this rare complication with Dr. B C shah.

General advice

The operation to untwist, fix and save the testis is successful in 80 to 100 per cent of cases if it is done within four to six hours from the moment the problem started and your child developed pain.

If the operation takes place six to eight hours after the initiation of the problem the chances of success are dramatically smaller and after 12 hours are diminished. Therefore, in the future, it is important to know that if you have even the slightest suspicion that one of your children develops a similar problem, it is vital to come to the hospital urgently.

These notes will help you and your son through your child's operation. They are a general guide. They do not cover everything. Also, all hospitals and surgeons vary a little.

If you have any queries or problems, please ask Dr.B C Shah.

Testicle Removal (Orchiectomy)

Orchiectomy is the removal of the testicles. The penis and the scrotum, the pouch of skin that holds the testicles, are left intact. An orchiectomy is done to stop most of the body's production of testosterone, which prostatecancer usually needs in order to continue growing.

What To Expect After Surgery

Orchiectomy can be done as an outpatient procedure or with a short hospital stay. Regular activities are usually resumed within 1 to 2 weeks, and a full recovery can be expected within 2 to 4 weeks.

Why It Is Done

Orchiectomy may help relieve symptoms, prevent complications, and prolong survival for advanced prostate cancer. Radiation treatment is sometimes needed also.

How Well It Works

Orchiectomy often causes the tumor to shrink and relieves bone pain.

This surgery does not cure prostate cancer, although it may prolong survival.

Risks

Orchiectomy causes sudden hormone changes in the body. Side effects from hormone changes include:

• Sterility.
• Loss of sexual interest.
• Erection problems.
• Hot flashes.
• Larger breasts (gynecomastia).
• Weight gain.
• Loss of muscle mass.
• Thin or brittle bones (osteoporosis).

What To Think About

Removing the testicles is one way to cut down on testosterone and other male hormones, or androgens. Taking medicine is another way to reduce androgen levels in your body. Some men may prefer surgery over taking pills or having injections. But if you choose to take medicine, you can stop taking the hormone drugs. And the side effects from taking medicine may go away. An orchiectomy is permanent.

Some men choose to have reconstructive surgery after an orchiectomy, in which Dr. B C Shah replaces the testicles with artificial testicles.

512 stones found in Gall bladde

(Dr. B C Shah recently performed Laparoscopic Cholecystectomy on Mr. N_____ G______ who had 512 stones!)

Mr. N_____ G______ came to me with history of chronic pain in upper abdomen. The pain would get aggravated after meals. His sonography revealed that his gall bladder was distended & full of stones. I performed Laparoscopic Cholecystectomy on him. It was a difficult case as there were lot of adhesions. The gall bladder was delivered successfully  It was a pleasant surprise to find 512 stones in the Gall Bladder. 

One often wonders as to why patients wait so long. Many times patients come to me with Gall Stones. Often they have only one small stone. The common question asked is "Do I still need surgery for just a small stone?"

As per my observation of last 23 years, one stone or many stones – all have a potential to create complications including even death. Its not just the numbers or size. One small stone can just simply slip into the bile duct and is sufficient to trigger Pancreatitis. I personally know of a patient who developed severe pancreatitis due to a 3 mm small stone. She battled for two months in one of the best hospitals in Mumbai and ultimately died. 

In kidney stones, one of the criteria on which the therapy is based is the number of stones and its size. Smaller stones can pass out spontaneously and the patient's problem gets solved naturally. However, this is not the situation with gall stones. A gall stone or its fragment passing out can be dangerous as it can cause blockage of bile in liver or swelling in pancreas. Such complications can occur any time and no doctor on earth can predict when this will occur.

Many patients wait for the stones to grow and multiply. Surely this has a potential of inviting big untimely trouble. Don't wait. There are no warning signs.As far as records go, the largest number of gallstones removed was 3,110 in an open surgery in Britain in 1983, reported in the Guinness Book of World Records. 

Gallstone Ileus

Description

Gallstone ileus is obstruction of the bowel due to impaction of one of more gallstones. To achieve this, stones usually have to be at least 2.5 cm in diameter.

A fistula develops between a gangrenous gallbladder and the duodenum or other parts of the gastrointestinal tract, allowing passage of the stone. Occasionally the stone may enter the intestine through a fistulous communication between the bile duct and the gastrointestinal tract. Stones less than 2.5 cm in diameter may traverse the alimentary canal without causing obstruction. When the gallstone lodges in the duodenum and causes gastric outlet obstruction, it is called Bouveret's syndrome.

Epidemiology

It accounts for only about 1-4% of causes of intestinal obstruction, but up to 25% of cases of intestinal obstruction in those over the age of 65. It is more common in women than in men and the incidence reflects the prevalence of gallstones with age and sex. It is regarded as 'rare and controversial'.

The most common site of impaction of gallstones is in the distal ileum, followed by the jejunum and the stomach.

Presentation

The presentation is usually that of distal obstruction of the small bowel but the symptoms and signs of gallstone ileus can be vague. It is important to make the diagnosis, as there is a high mortality in the usual age group.

Symptoms

Abdominal pain is an early sign with vomiting developing later. It tends to become progressively more severe.

Abdominal pain is colicky in nature, with freedom from pain between spasms. It is periumbilical and is not clearly localised.

Abdominal distension develops.

Initially the patient may pass stools or flatus but not later.

Vomiting occurs some hours after the onset of pain and it may be faeculent.

Signs

Patients with gallstones are often, but not invariably, obese.

The patient tends to look unwell.

The abdomen may be bloated and small bowel peristalsis may be visible.

Some slight and nonspecific tenderness of the abdomen is common.

Auscultation will reveal rushes, gurgling and tinkling sounds at times of pain.

Features of dehydration will develop.

Differential diagnosis

This is between other causes of intestinal obstruction. This may include adhesions from previous surgery. Malignancy almost never occurs in the small intestine. Large bowel malignancy tends to present as chronic blood loss when proximal and obstruction when distal. This is because the contents of the bowel are liquid in the first part and become progressively more solid as they traverse the colon.

Investigations

Plain abdominal X-ray should show the typical features of small intestinal obstruction. It may be possible to see air in the biliary tract. It may be possible to see a radio-opaque gallstone.

Rigler's triad of small bowel obstruction, pneumobilia and ectopic gallstones may be occasionally detected by plain radiograph or ultrasound. Computed tomography (CT) scanning invariably demonstrates a fistulous communication, intraluminal gallstone in the small bowel, pneumobilia and any other co-existing pathology contributing to the impaction of the gallstone. The interpretation of subtle signs on CT scanning requires skill but can increase the accuracy of the diagnosis. From the practical perspective, plain abdominal films demonstrate small bowel obstruction, ultrasound shows biliary tract pathology and CT makes the final diagnosis. Helical CT can be especially useful.

Blood tests should include FBC, U&E and creatinine, and LFTs.

In an elderly person, routine CXR and ECG before anticipated surgery are wise.

In view of anticipated surgery, blood should be group and cross-matched.

Associated diseases

Patients with gallstone ileus are often old and frail. Cases of gallstone ileus have been reported in patients whose intestines are strictured due to tuberculosis or other disease.

Management

An intravenous infusion is required to correct dehydration and to reduce the risk of surgery.

A nasogastric tube will decompress the stomach and avoid further vomiting.

Removal of the obstruction at laparotomy should be accompanied by a careful search for other gallstones proximal to the obstruction. It is generally recommended that those with chronic gallstone problems should undergo a later cholecystectomy, but it can be performed concurrently. Some authors say that definitive treatment of biliary pathology at the initial operation is the management of choice. Others disagree as it is a longer operation in a high-risk group and so the risk of complications is increased. One retrospective study concluded that treatment should be individualised and that removal of the stone through the bowel (enterolithotomy) should only be accompanied by cholecystectomy if the patient has good cardiorespiratory reserve and with absolute indications for biliary surgery at the time of presentation (the one-stage procedure).

Some surgeons manage to use a laparoscopic technique.

Complications

Complications are common as this is major surgery, usually in a group who are old and frail.

Prognosis

Because the condition tends to affect the old and frail, there is a 20% mortality. There appears to be no real difference in terms of the operative procedure performed, eg simple enterolithotomy to fistula repair

Miraculous healing from Burn Injuries

Hare Krishna Shri. K. Venkataramana,

 I would like to express my deepest gratitude to you and the staff of your hospital for taking such a good care of my employee by the name Mr. Bhagyawan Behra. He had suffered burn injuries and was admitted to your hospital on 10th February 2013.

He was discharged from your hospital on 24/02/2013. It was miraculous recovery, considering the fact that whoever saw his burn injuries in the beginning was not sure of his recovery at all.

I sincerely feel that your hospital's holistic approach to patient care, is truly been helpful to his recovery and your motto, "Serving in Devotion", which is followed in spirit by every individual staff of your hospital, has been the secret behind his miraculous recovery.

Not only he received quick and highly professional care, but more than that he received care with love and compassion.

I am very grateful for the professional and personal service he received during his stay is already feeling much better.

Please give my regards and thanks to your winderful team of dedicated professionals, for an outstanding spirit in the execution of medical services.

Hare Krishna!                                                                                                                                                                            

Your's Sincerely,                                                                         

Ashok  K Shah             

Misdiagnosis can lead to rupture of appendix

Mr Khokan Roy, 30 yr resident of Bhyander came in emergency with complaints of pain in abdomen & vomiting since 3 days. So far he was taking treatment from a local general practitioner, who just gave him medicines  thinking it to be acidity problem. Patient tolerated pain hoping to get better with his family doctor's medicines. but his condition slowly deteriorated in next two days as he continued to vomit & have increasing pain in abdomen. Clinical examination of this patient was sufficient to reach to the diagnosis of acute appendicitis. Subsequently his sonography confirmed that there was swelling in appendix. He was explained about the disease and prepared for emergency surgery – removal of the appendix. He was offered options of open appendectomy as well as key hole (laparoscopic) surgery. He said that he would not be able to take long leave and thus opted for Laparoscopic appendectomy.The operative findings were that the appendix had burst & lot of pus had formed around appendix. Waiting for three days had caused the appendix to burst and spread of pus. The surgery was carried out successfully – removal of the appendix along with the pus. A drainage tube was placed for couple of days to let out the inside toxins. The patient made a rapid & uneventful recovery & the wounds healed very well..
Although appendix is situated in right lower abdomen, the initial manifestation of the disease can be upper or central abdominal pain. This is called refereed pain. Often such patients are diagnosed & treated for acidity. Important time is lost and such appendix are prone to rupture and cause more trouble to patient. A proper clinical examination along with the aid of ultrasonography can prevent such disasters.

Intestinal Obstruction due to Stones

MRS R____ K________ , a 55 year old female was transferred from a local nursing home

She was admitted in a local Nursing home with abdominal pain & vomiting. She was treated as a case of acidity. In spite of the treatment for a week, she did not improve. 

When she came to me, her symptoms  were suggestive of intestinal obstruction (blockage). A CT scan of abdomen was undertaken. CT scan revealed that she had intestinal obstruction due to a large 5 centimeter stone. This is called Gall stone ileus.

How did the stone land up in her intestine?

No it was not a swallowed stone. This stone had formed in her Gall Bladder over many years. Due to its weight & chronic inflammation, the stone gradually perforated into her small intestine (duodenum). Since the stone was very large it could not pass thro the small intestine and got stuck in the last part of small intestine. Patient was having pain & constantly vomiting due to this blockage. 

The treatment was done using minimal access surgery instead of making a big cut on her abdomen – laparotomy. Using laparoscopy, the site of blockage was identified. A small incision was made on her abdomen. The stone was cut open from the intestine (enterolithotomy) and the intestine was placed back into the abdomen.

How did the stone land up in her intestine?

No it was not a swallowed stone. This stone had formed in her Gall Bladder over many years. Due to its weight & chronic inflammation, the stone gradually perforated into her small intestine (duodenum). Since the stone was very large it could not pass thro the small intestine and got stuck in the last part of small intestine. Patient was having pain & constantly vomiting due to this blockage. 

The treatment was done using minimal access surgery instead of making a big cut on her abdomen – laparotomy. Using laparoscopy, the site of blockage was identified. A small incision was made on her abdomen. The stone was cut open from the intestine (enterolithotomy) and the intestine was placed back into the abdomen.

thyroid-gland-removal

What is a thyroidectomy?

A thyroidectomy is surgery to remove all or part of the thyroid gland.The thyroid gland is a small gland in the lower front of your neck. It takes iodine from the food you eat to make hormones. The hormones control the process of turning the food you eat into energy.

When is it used?

You may need to have part or all of your thyroid gland removed if: You have a lump in your thyroid gland that could be cancer. If cancer is found, removal of the gland can keep the cancer from spreading.Your thyroid gland is overactive and making too much thyroid hormone (a problem called hyperthyroidism).Instead of this procedure, other treatments may include:If you have a lump, you may choose to have repeat exams over many months or years and then have surgery if the lump grows. If you have cancer in your thyroid gland, there is some risk that the cancer will spread to other parts of your body.If you have an overactive thyroid gland, medicine and radioactive iodine treatments can usually control the problem. You may need surgery if these treatments do not control your thyroid gland.You may choose not to have treatment. Ask Dr. B C Shah about your choices for treatment and the risks.

How do I prepare for this procedure?

Make plans for your care and recovery after you have the procedure. Find someone to give you a ride home after the procedure. Allow for time to rest and try to find other people to help with your day-to-day tasks while you recover.Follow your provider's instructions about not smoking before and after the procedure. Smokers may have more breathing problems during the procedure and heal more slowly. It is best to quit 6 to 8 weeks before surgery.Some medicines (like aspirin) may increase your risk of bleeding during or after the procedure. Ask Dr. B C Shah if you need to avoid taking any medicine or supplements before the procedure.You may or may not need to take your regular medicines the day of the procedure, depending on what they are and when you need to take them. Tell Dr. B C Shah about all medicines and supplements that you take.Your provider will tell you when to stop eating and drinking before the procedure. This helps to keep you from vomiting during the procedure. Follow any other instructions your healthcare provider gives you.Ask any questions you have before the procedure. You should understand what your healthcare provider is going to do.

What happens during the procedure?

This procedure will be done at the hospital.You will be given general anesthesia to keep you from feeling pain. General anesthesia relaxes your muscles and you will be asleep. Dr. B C Shah will make a cut in your neck just above the collarbone. He or she will then remove all or part of the gland. Lab tests will be done right away during the procedure to check for cancer. Based on the test results, the provider may end the operation or may remove another part or all of the thyroid gland. The cut in your neck will then be closed. Rarely, thyroid cancer spreads to lymph nodes. If this has happened, you will need further treatment.The procedure will take 1 to 3 hours.

What happens after the procedure?

You may be in the hospital for 1 or 2 days. If all or a large part of the thyroid gland was removed, you will need to take thyroid hormone medicine for the rest of your life. If you have cancer, you may need to take radioactive iodine medicine to destroy any remaining thyroid tissue and cancerous cells. Ask Dr. B C Shah:how long it will take to recoverwhat activities you should avoid and when you can return to your normal activitieshow to take care of yourself at home what symptoms or problems you should watch for and what to do if you have them. Make sure you know when you should come back for a checkup.

What are the risks of this procedure?

Dr. B C Shah will explain the procedure and any risks. Some possible risks include:Anesthesia has some risks. Discuss these risks with your healthcare provider.You may have infection or bleeding.The nerves that control your speech may be injured. Damage to the nerves could make your voice hoarse. The damage may be temporary or lifelong.The parathyroid glands may be injured when all of the thyroid gland is removed. The hormones made by the parathyroid glands control the amount of calcium and phosphorus in the blood. You need to have the right levels of calcium and phosphorus in your blood so your nerves and muscles work well. If the parathyroid glands cannot function after the operation, you may need to take calcium pills or hormones.If thyroid cancer is found, it can return to the neck or other parts of the body. Fortunately, removal of the thyroid gland usually keeps this from happening.There is risk with every treatment or procedure. Ask your healthcare provider how these risks apply to you. Be sure to discuss any other questions or concerns that you may have.