Acute puerperal uterine inversion is a life-threatening and unpredictable obstetric emergency. If overlooked, it could lead to a maternal death. Although the precise cause is unknown, it is postulated to be caused by the mismanagement of the third stage of labor with premature traction of the umbilical cord and fundal pressure before placental separation. At the Ipoh General Hospital in Malaysia there were 31 394 deliveries and four acute uterine inversions occurring from 1 January 2002 to 30 June 2005. The four patients were between 25 and 36 years of age and their parities were between two and three. When manual repositioning of the uterus failed, successful correction was accomplished by the O'Sullivan's hydrostatic method. One case had to undergo subtotal hysterectomy after repositioning because of massive hemorrhage secondary to placenta accreta. Early diagnosis, immediate treatment of shock, and replacement are essential.
A bleeding pseudoaneurysm of the peripancreatic artery can present with massive upper gastrointestinal hemorrhage. History of pancreatitis and urgent imaging are crucial in the making of the diagnosis. Here, we report a patient with alcoholic chronic pancreatitis presented with ruptured pseudoaneurysm of gastroduodenal artery (GDA). He was treated with percutaneous angiographic embolisation.
Lower gastrointestinal bleeding is usually due to haemorrhoids, diverticular disease, or colorectal cancer. Infective causes of gastrointestinal bleeding are rare. A 70-year-old lady was admitted with septic shock secondary to community acquired pneumonia. She later developed massive lower gastrointestinal bleeding secondary to colonic mucormycosis. Her condition deteriorated rapidly and she died of septicemia. Mucormycosis of the colon is extremely rare and is still associated with a high mortality.
Jejunal diverticulosis is a rare gastrointestinal condition manifested as benign outpouching from the jejunal wall. It is usually asymptomatic, but may present as obscure gastrointestinal bleeding. This condition is often found incidentally in the imaging work-up of patients with other gastrointestinal conditions. We present a case of jejunal diverticulosis in a 65-year-old gentleman with obscure overt gastrointestinal bleed.
Haemorrhage arising from gastric arteriovenous malformation (AVM) is rare and normally occurs in the elderly. Bleeding gastric AVM presenting in the younger age group is even rarer. We report a case of a 14 year old boy who presented with recurrent episodes of haematemesis. He subsequently underwent a proximal gastrectomy and the histological examination confirmed a gastric AVM. After reviewing the literature we believe this is the youngest ever reported case of bleeding gastric AVM reported in English literature.
We report a case of a patient with hypertension and ischaemic heart disease on anti-platelet treatment, who developed uniocular profound visual loss from a submacular haemorrhage secondary to valsalva retinopathy. He was treated with a combination of intravitreal recombinant tissue plasminogen activator (rtPA) and sulphur hexafluoride (SF6) gas followed by strict prone positioning. He demonstrated significant displacement of the haemorrhage and improvement of vision postoperatively.
This retrospective study evaluated patients admitted to the Department of Gastroenterology, Singapore General Hospital for variceal bleeding in the year 2004. Improvement in outcome of variceal bleeding has been reported in the West. There is no regional data on this condition. This study aims to determine the characteristics and outcome of variceal bleeding in a tertiary hospital in Southeast Asia. Twenty-two patients were eligible. The main aetiologies of liver cirrhosis were chronic hepatitis B (38%) and alcohol (33%). Child's A, B and C were 29%, 48% and 24% respectively. Nineteen patients (86%) had bleeding oesophageal varices (band ligation performed). The remaining three patients (14%) had bleeding gastric varices (N-butyl-2-cyanoacrylate injection performed). Detailed description of certain endoscopic findings was absent in up to 18 patients (82%). All patients received antibiotics and vasoactive drug. In-hospital mortality and rebleeding were 9% and 18% respectively. We conclude that the relatively low in-hospital mortality and rebleeding rates in our series are most probably due to the smaller proportion of patients with severe liver dysfunction and management which adhered to recommendations. Documentation of endoscopic findings needs to be improved to facilitate the continuation of care.
Postpartum is a crucial period for a mother. During this period a mother is going through the physiological process of uterine involution and at the same time adapting to her new role in the family. Many postpartum complications occur during this period. Among the important obstetric morbidities are postpartum hemorrhage, pregnancy related hypertension, pulmonary embolism and puerperal sepsis. Common surgical complications are wound breakdown, breast abscess and urinary fecal incontinence. Medical conditions such as anemia, headache, backache, constipation and sexual problems may also be present. Unrecognized postpartum disorders can lead to physical discomfort, psychological distress and a poor quality of life for the mothers. Providing quality postnatal care including earlier identification of the problems (correction) and proper intervention will help the mother to achieve full recovery and restore her functional status back to the pre-pregnancy state sooner.
The aim of this study was to evaluate the morphological and biological properties of a locally produced "Bovine Bone Sponge" for use in dentistry. Bovine bone sponge was prepared from local calf bone. Endotoxin level and surface properties were investigated. The pore size and water uptake ability were measured and results were compared with the commercial haemostatic agent. The material was tested for its haemostatic property and its inhibition of alveolar bone resorption in a sheep model following dental extraction. Results revealed a significant difference in haemostatic effect, and a shorter bleeding time and a lower rate of alveolar bone resorption in bovine bone sponge compare to a commercial haemostatic agent.
A case of spontaneous rupture of uterine artery in the second trimester of pregnancy is described. Haemorrhage from rupture of uterine artery during pregnancy was discovered at laparotomy. This was an unusual but serious complication of pregnancy. This condition is extremely rare and one must consider it in cases of incomprehensible abdominal pain with or without haemodynamic collapse. A review of the literature revealed only four similar cases so far. This pregnancy continued till 37 weeks pregnancy and had a spontaneous vaginal delivery. Immediate institution of effective resuscitative measures and early surgical intervention were essential to both foetal and maternal survival.
Despite advancements in endoscopy and pharmacology in the treatment of peptic ulcer disease the overall mortality has remained constant at 10% for the past four decades. The aim of this study was to determine the age, gender, racial distribution, incidence and causes of endoscopically diagnosed cases of upper gastrointestinal (UGI) bleeding to summarise treatments undertaken and to report their outcome. A prospective study of UGI bleeding in 128 patients was performed in two surgical wards of Kuala Lumpur Hospital, involving both elective and emergency admissions. The study group comprised of 113 (88.2%) males and 15 (11.7%) females. The mean age was 51.9 years (range 14 to 85 years) and 37.5% (48 of 128 patients) were older than 60 years. The Indian race was over-represented in all disease categories. Smoking (50.1%), alcohol consumption (37.5%), non-steroidal anti-inflammatory drugs (NSAIDs) (17.2%), traditional remedies (5.5%), anti-coagulants (2.3%) and steroids (0.8%) were among the risk factors reported. Common presenting symptoms and signs included malaena (68.8%), haematemesis (59.4%) and fresh per rectal bleeding (33.6%). The commonest causes of UGI bleeding were duodenal ulcer (32%), gastric ulcer (29.7%), erosions (duodenal and gastric) (21.9%), oesophageal varices (10.9%) and malignancy (3.9%). UGI bleeding was treated non-surgically in 90.6% of cases. Blood transfusions were required in 62.6% (67/107) of peptic ulcer disease patients. Surgical intervention for bleeding peptic ulcer occurred in around 10% of cases and involved under-running of the bleeding vessel in most high risk duodenal and gastric ulcer patients. The overall mortality from bleeding peptic ulcer disease was 4.7%. Six patients died from torrential UGI haemorrhage soon after presentation, without the establishment of a cause. Active resuscitative protocols, early endoscopy, more aggressive interventional therapy, early surgery by more senior surgeons, increasing intensive care unit beds and more active participation of multidisciplinary teams in co-ordinating management are among remedial measures advocated. Broader educational preventive strategies should target the causes of UGI bleeding.
Near-miss cases in life-threatening obstetric patients occurring over a one year period are analysed retrospectively with regards to morbidity measured in terms of hospital stay, utilisation of high dependency ward and intensive care beds and adequacy of clinical management. One-hundred and twenty two cases occurred among 9932 deliveries. Massive obstetric haemorrhage (54.2%) and hypertensive disorders of pregnancy (36.9%) were the two main diagnostic groups. Seventy one (58.2%) cases were referred from peripheral centres for obstetric management and 77 (63.1%) were not booked at this hospital for antenatal care. A majority were not ill-looking (92 cases) at the time of admission but turned for the worse in the course of labour. Interventional measures taken in clinical management were considered appropriate in all cases. Delay in instituting treatment was present in 6 cases. Remediable measures were recognised in 15 (12.3%). This study, apart from supplementing mortality audits, demonstrates that high risk obstetric patients can be triaged at the time of admission to labour wards by trained midwives and junior doctors in busy obstetric units without compromising standards of care.
Study site: Obstetric and Gynaecologic Unit in Ipoh Hospital.
Variceal bleeding is the most important complication of portal hypertension. Mortality due to the first variceal bleeding is very high (50%) and of those surviving a variceal bleeding episode, up to 80% may rebleed. Proper management of the acute variceal bleeding episode, the prevention of rebleeding and primary prophylaxis for variceal haemorrhage are therefore mandatory in order to improve the morbidity and mortality of cirrhotic patients with variceal bleeding. Injection sclerotherapy would be the treatment of choice for acute variceal bleeding. Drug treatment in the form of either a combined vasopressinnitroglycerin regimen or somatostatin may be used as an alternative. Patients not responding to these treatments should be referred for surgery. For the prevention of variceal rebleeding, non-selective betablockers should be tried first, reserving long-terminjection sclerotherapy for patients with contraindications or intolerance to beta-blockers or in whom beta-blocker therapy has failed. Surgical rescue in the form of either shunt surgery or lever transplantation should be considered if either treatment fails. A new technique, transjugular intrahepatic portosystemic stent-shunt (TIPSS) may replace shunt surgery in the future. Beta-blockers is the treatment of choice for primary prophylaxis of variceal haemorrhage and has a role in preventing acute and chronic bleeding from congestive gastropathy. However, the above sequential approach from the least invasive to the more invasive therapeutic options may not be appropriate for all cirrhotic patients with variceal bleeding.
This report deals with a young man who developed features of haemophogocytosis during the course of typhoid fever. The pertinent clinical and laboratory features of typhoid-associated haemophagocytosis are discussed. The need for blood component replacement therapy in addition to specific anti-microbials to treat haemophagocytosis complicating typhoid fever is stressed.
This case report illustrates how a life-threatening renal bleeding which has failed to be controlled by open surgery can be elegantly managed by a minimally invasive technique of interventional radiology. It also allows maximal conservation of renal tissue so that the patient can avoid chronic dialysis or renal transplantation.
Bleeding gastroesophageal varices is associated with a high morbidity and mortality. Forty-four cases of bleeding gastroesophageal varices were treated at the Department of Surgery, Universiti Kebangsaan Malaysia, General Hospital, Kuala Lumpur over four and a half years. Thirty-two of them had liver cirrhosis. Hepatitis B infection was noted in 13 and alcoholic abuse was present in 14 patients. Five patients had associated hepatoma. Thirty-four percent had gastric fundal varices and a third of these bled from them. A total of 179 endoscopic injection sclerotherapy sessions were performed averaging 4 per person. Rebleeding rate was 4% and mortality was high (50%) in these cases. It was concluded that injection sclerotherapy is a safe and effective means of controlling bleeding oesophageal varices. Operative surgery was employed in those who rebled after injection and would be considered in those in Child's A.
Massive postpartum haemorrhage after Cesarean section for placenta previa is a common occurrence. The bleeding is usually from the placental bed at the lower uterine segment. Uterine tamponade has a role in the management of such patients especially when fertility is desired. We describe here a case of massive postpartum haemorrhage, which was managed, with the use of a Sengstaken-Blakemore tube. This allowed us to avoid a hysterectomy for a young primiparous patient.
We retrospectively analyzed all patients presenting with upper gastrointestinal bleeding to Seremban Hospital over a one-year period. A quarter of the oesophagogastro-duodenoscopies (OGD) performed were performed as emergency for upper gastrointestinal tract bleeding. Gastric ulcers and duodenal ulcers were the two most common findings. Our results suggest that there is a male preponderance of 2:1, the Chinese were more likely to be affected and the elderly (> 60 years) were at highest risk.