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Bezoars are retained concretions of undigested foreign material that accumulate and coalesce within the gastrointestinal tract, most commonly in the stomach. A 12 years old male child presented to us with complaints of pain upper abdomen on and off for 2 months. He had a habit of biting and chewing doormat at home for several months. Physical examination revealed mild epigastric tenderness. Upper GI endoscopy revealed a mass of fibres in the stomach which was tightly organised and too large to safely remove endoscopically in toto. Hence patient was taken up for surgery and a mass of around 9×6 cm in size and oval in shape was removed from stomach. Postoperative recovery was uneventful. Doormatobezoars are rare cause of pain abdomen which can be treated safely and effectively surgically.

Background: Although burns are a major problem in health care, a lot of the variation in risk factors exists from region to region which if uncovered correctly could help take effective prevention measures. Aims and Objectives: To assess the 3-year (January 2012 to January 2015) epidemiology of burn injuries admitted to our hospital (primary objective) and to find areas of improvement in burn care (secondary objective). Materials and Methods: After obtaining ethical approval data were obtained from the medical record section regarding age, sex, residence, occupation, marital status, socioeconomic status, dates of admission and discharge, circumstances regarding the place, intent, cause, and source of heat. Clinical assessment was done using Wallace's “Rule of Nine” in adult and “Lund and Browder” chart in the pediatric age groups. The interrelationships between clinical and epidemiological variables with burn injury were studied. Results: An increasing trend in the admission rates of burn victims noted in last 3 years males (55.47%) outnumbered females (44.52%). The most common age group affected is older children, adolescents, and young adults (between 11 and 30 years). Flame (38.3%) and scald (25.3%) burns contributed to most of the injuries. Females (52.30%) are the major victim of flame burns. Electrical and chemical burns affected only the males suggesting work-related injuries. Trunk (30.8%) is the most severely affected site in all cases. Depression (6.8%) and power line workers (4.7%) seem to be important risk factors in our study. Inability to complete treatment (26.7%) was a major concern in our study. Conclusions : This study highlights the need for proper burn care that could be provided at the primary health-care level. The majority of burns were accidental in nature in school going children, young adults, and females. Flame and scald burns were the most common cause. Preventive measures directed toward burn safety and first aid measures may improve the outcome in burn injuries.

Background: Ascaris lumbricoides is the largest intestinal nematode parasite of humans. This study describes different presentations and management patterns of gastrointestinal and hepato-pancreato-biliary ascariasis presenting to a tertiary centre of North-eastern India.Methods: This was a prospective observational study aimed to study the presentations and management patterns of Ascaris related surgical diseases including intestinal obstruction, pancreatitis and cholangitis in a tertiary centre of Northeast India. All consenting cases of gastrointestinal and hepato-pancreato- biliary ascariasis admitted in our hospital were included.Results: Ninty patients with Ascaris sequeale were included, which included biliary ascariasis without cholangitis: 36, pancreatitis: 30, cholangitis: 18 and sub-acute intestinal obstruction: 6. Ultrasound was the most useful diagnostic investigation followed by stool examination and endoscopy. Hepato-pancreato-biliary ascariasis was managed conservatively and the progress monitored with sonography. The surgical management choledocho-duodenostomy was done for three patients having biliary ascariasis with unresolving obstructive jaundice and recurrent cholangitis on conservative management and 6 patients underwent therapeutic endoscopic worm removal. There were no deaths. No patient needed ICU care.Conclusions: Sonography can be helpful in diagnosing the presence of worms, its complications and in evaluating response to treatment. Hepato-pancreato-biliary ascariasis can be managed conservatively for majority of the patients.

Introduction: Laparoscopic Cholecystectomy (LC) has numerous benefits over the open method; still postoperative pain remains an issue. Postoperative pain, requiring injectable analgesics prolong the patient’s hospital stay, and is one of the hurdles in performing LC as a day-case surgery. Aim: To assess the analgesic effect of Intraperitoneal (IP) administration of Inj. Bupivacaine±Inj. Tramadol in patients undergoing LC. Materials and Methods: A total of 100 patients scheduled for LC were enrolled in the study after meeting the inclusion criteria. Patients were randomly divided into 3 groups. Patient allocated to Group A received 30 mL of inj. normal saline IP, Group B received 30 mL of 0.25% inj. bupivacaine and Group C received 30 mL of 0.25% inj. bupivacaine along with 100 mg inj. tramadol. The local anaesthetic/analgesic or placebo solution was sprayed on the upper surface of the liver and on right subdiaphragmatic space and over gall bladder bed. The pain intensity of pain for patients in all the three groups were recorded using VAS at 0, 1, 2, 6, 12 and 24 hours after surgery. The student t-test was used to compare mean pain score between groups. The p-value ≤0.05 was taken as significant. Results: There was statistically significant difference in postoperative pain intensity in group A vs groups B (p

Advanced mucinous ovarian cancer is a separate entity and has different biological behaviour. There is a wide range of therapeutic challenges and dilemmas in the management of these patients. The authors present a case of advanced ovarian mucinous cystadenocarcinoma with pseudomyxoma peritonei who had poor response to standard neoadjuvant chemotherapy. This case is highlighted to emphasize the challenges in the decision making for the management of advanced mucinous ovarian cancer.

Introduction: Alcoholic Liver Disease (ALD), which consists of three major diseases: (1) fatty liver, (2) alcoholic hepatitis and (3) cirrhosis, is described to be associated with lymphopenia and an altered ratio of lymphocyte subsets but the reported results are not uniform. Aim: To compare the Absolute Lymphocyte Counts (ALC) and its subsets including T-helper 17 (Th17) or Interleukin 17 (IL17) secreting lymphocyte subsets between ALD patients and controls and to correlate these findings with biochemical and radiology findings. Materials and Methods: Forty cases of ALD at various stages of presentation were included in the study along with equal number of age and sex matched healthy controls. Ultrasound abdomen and liver function tests were done in all cases. Peripheral blood was collected and subjected to flow cytometric analysis for estimation of CD3, CD4, CD8 and Th17 cells. Results: On ultrasound, 13, 19 and 8 cases were found to be fatty liver, chronic hepatitis and cirrhosis respectively. With advanced stage of ALD, there was a significant decrease in ALC, CD3, CD4 and CD8 and while Th17 increased markedly. ROC curves were made and Th17% of 2.44 was found to be the optimum level for predicting progression to chronic hepatitis and 6.07 for cirrhosis. Conclusion: Th17 levels increase while ALC, CD3, CD4 and CD8 cells decrease with advancing stage of liver disease. These may be potential markers for staging and prognostication of ALD.

A pancreatic pseudocyst arises as a result of acute or chronic pancreatitis, pancreatic trauma, or obstruction of the pancreatic duct by a neoplasm. Most of the pseudocysts are located within the head and the body of the pancreas but 20% are extra-pancreatic. We report a case of a 33-year-old gentleman presenting with acute on chronic alcoholic pancreatitis with hepatic sub-capsular pseudocyst involving left lobe of liver, with intra-cystic bleed was successfully treated with Ultrasonography (USG) guided drainage. Computed tomography (CT) and high level of amylase in the collection plays an important role in diagnosing this condition. Large hepatic sub-capsular pseudocyst presenting with severe pain due to intra-cystic bleed can be treated with percutaneous drainage to pre-empt rupture.

Tubercular esophagocutaneous fistula is a rare entity with only about four cases reported so far. We report here a case in a young female who has a very long tract but responded well to antitubercular treatment.

There are many medical causes of abdominal pain; abdominal epilepsy is one of the rarer causes. It is a form of temporal lobe epilepsy presenting with abdominal aura. Temporal lobe epilepsy is often idiopathic, however it may be associated with mesial temporal lobe sclerosis, dysembryoplastic neuroepithelial tumors and other benign tumors, arterio-venous malformations, gliomas, neuronal migration defects or gliotic damage as a result of encephalitis. When associated with anatomical abnormality, abdominal epilepsy is difficult to control with medication alone. In such cases, appropriate neurosurgery can provide a cure or, at least, make this condition easier to treat with medication. Once all known intra-abdominal causes have been ruled out, many cases of abdominal pain are dubbed as functional. If clinicians are not aware of abdominal epilepsy, this diagnosis is easily missed, resulting in inappropriate treatment. We present a case report of a middle aged woman presenting with abdominal pain and episodes of unconsciousness. On evaluation she was found to have an intra-abdominal foreign body (needle). Nevertheless, the presence of this entity was insufficient to explain her episodes of unconsciousness. On detailed analysis of her medical history and after appropriate investigations, she was diagnosed with temporal lobe epilepsy which was treated with appropriate medications, and which resulted in her pain being relieved.

L. M. Darlong ( ) E-mail: lmdarlong@gmail.com It is a rare condition in which emphysematous bulla develop in the lung with the alveolar spaces gradually disintegrating to form large air sac and fi nally all the alveolar air sac combining to form a large or giant bulla which eventually replaces a major part of the lung parenchyma resulting in vanishing lung syndrome, originally described by Burke in 1937 [1]. The term is also used when a bulla occupies more than one-third of the haemithorax. Most of the patients affected are young male, smokers. High-resolution computed tomographic (HRCT) scan is an important tool for assessment [2, 3]. Bullous disorder of the lung is primarily a medical problem, although surgical intervention using video-assisted thoracic surgery (VATS) is benefi cial in reducing chronic and disabling dyspnoea and in the management of specifi c complications such as pneumothorax, infection, haemoptysis or chest pain [1, 2]. Most authors agree that preventive surgery is indicated when the bulla occupies half or more of the haemithorax, compresses the normal lung, or has enlarged over a period of years [1, 4]. The natural history of such untreated giant bulla is usually dead due to respiratory failure [1]. A 20-year-old boy was detected during a routine chest X-ray to have a bullous lung disease on the right side (Fig. 1). There was no history of smoking, chest pain, recurrent cough or fever, he had mild dyspnoea medical research council (MRC) dyspnoea scale of 2. Physical IMAGES IN SURGERY

Staghorn calculus in the common bile duct (CBD) is rare. Few reports have described a giant stone measuring 5 cm or more in the CBD [1]. We could find only one published report of staghorn common bile duct calculus [2]. A 48-year-old lady presented with chronic pain upper abdomen and mild icterus. Ultrasonography followed by magnetic resonance cholangiopancreaticography (MRCP) showed dilated CBD impacted with stones (Fig. 1). The patient underwent open cholecystectomy and CBD exploration. At surgery, the stone was tightly impacted in the CBD and extended into both hepatic ducts, measuring approximately 8 cm × 6 cm (Fig. 2). The stone was extracted with difficulty and hepaticojejunostomy was done. The patient recovered uneventfully and was discharged from the hospital on 10th postoperative day.

Ascaris lumbricoides is a common intestinal parasite in tropical and temperate regions. Although usually asymptomatic, infection can lead to biliary or intestinal obstruction and very rarely obstruction of the main pancreatic duct due to its smaller lumen. We report two cases of ascariasis in the main pancreatic duct, which is not a common site, presenting as acute pancreatitis and recovering uneventfully with conservative management.

Intrauterine contraceptive devices have been in use for a long time as family planning measures, one of its complications of perforating the uterus and migrating into the peritoneal cavity is also well known. Retrieval in such cases depends on the location of the migrated intrauterine devices and involves laparotomy or laparoscopy. We present here such a case that migrated partially into the lumen of the rectosigmoid and was successfully removed using a colonoscope.