Fatema Jawad  ( 7/6, Rimpa Plaza, M. A. Jinnah Road, Karachi. )

Carcinoma of GaH Bladder. Zia, N., Qu reshi, AM. J.Surg., 1994;8:26-28.
A retrospective review of 20 cases of histologically proven carcinoma of gall bladder from the hospital record of 280 patients with gall bladder disease during the period January, 1988 to June, 1994 is presented. The rna)e to female ratio was 1:9 and the ages ranged between 35 to 81 years. The most common symptom was dyspepsia and anorexia, expen­enced by all 20 subjects whereas 15 had pain in right hypochondrium. Jaundice was found in 6 patients, mass in the right hypochondrium in 8 and weight loss in 12 individuals. Ultrasound examination reported cholelithiasis in 15 cases.
Pre-operative diagnosis of carcinoma of gall bladder could be made in 15 patients only. Cholecystectomy could be carried out in 4 cases whereas, 5 underwent partial cholecys­tectomy. Eleven patients could not be operated due to secondaries inthe liver. All the cases were adenocarcinomaon histopathological examination. Niven’s staging was used for deterniining the extent of the disease. It was observed that there were one patient each in stage 1 and 2, two in stage 3,5 in stage 4 and 11 subjects had stage 4, making the figure 55 percent of the total. Mortality could notbe known due to a poor follow-up.
An increasing incidence in malignant gall bladder disease has been reported by many workers from the Indo­Pakistan Subcontinent. It is more common in females and is encountered at a relatively younger age as compared to the west. Gall stones have been associated with this malignancy and delay in treatment due to difficulty in pre-operative diagnosis and awareness is an important contributory factor.
The introduction of modern high resolution ultrasound machines, has made it possible to getanearly diagnosis. As the investigation techniques are not only expensive but also not available in every area, so it is advisable that once the diagnosis of cholecystitis or cholelithiasis has been made. surgery should not be delayed. The procedure is simple and without complications in most centres and the patient is saved from malignant changes taking place and a long term survival is had in those who have the early stage involvement.
Hepatic Tuberculosis - An Atypical Presentation. Shah, S.A., Malik, A., Baig, I.U. J.Pak.Instit.Med.Sci., 1994;5:293-295.
The case of a 35 year old male, diagnosed as hcpatic tuberculosis is presented. He came in with intermittent high grade fever, anorexia and weight loss of six months duration.
An initial diagnosis of liver abscess was made. Mild pyrexia was present and besides a palpable liver 3 cm below the costal margin, all other systemic examination was normal. All laboratory investigations were in the normal range except for the haemoglobin being 10.2 G/dl and an ESR of 90mm in the first hour.A rndio-isotope and a CT scan of the liver showed multiple focal defects in both lobes of the liver. Biopsy was attempted but was unsuccessful. An antibiotic trial did not give encouraging results. Finally laparotonw was performed. The liver showed multiple areas of caseating granulomatous inflaniniation from which specimens were taken for his­topathology. which gave a report of cascating granulornas suggestive of infection by mycobacterium tuberculosis. AFB was positive in the tissue. Anti-tubercular therapy was started, with rifampicin, isoniazid and mvambutol. The patient be­came afebrile after 6 days and gradually had an increase in weight.
Liver tuberculosis, an uncommon involvement, pre­sents either as a niiliary hepatic lesion or as focal tuberculosis with single or multiple confluent tubercles which can form tuberculomata. Rarely the bile ducts and canaliculi are involved. Hepatic tuberculosis occurs commonly due to haematogenous spread of the tubercle bacillus with a focus elsewhere. Diagnosis is difficult but due to a relatively frequent prevalence, it should be kept in mind in a case of pyrexia of unknown origin. Abdominal ultrasonography and radio-isotope scan alongwith a guided biopsy are useful investigations to establish a diagnosis.
Urinary Tract Infection (UTI) in Children. Wazir, M.D.K, Alam, M.M., Fauzi, S. PakJ.Med.Res., 1994;33:16-18.
One hundred and fifty cases with suspected UTI were studied in the paediatric department of Women and Children Hospital, Abbottabad. A detailed history was recorded and physical examination performed. Laboratory tests included blood picture, urine routine examination and culture. The urine sample was obtained through a suprapubic puncture technique under aseptic precautions. An abdominal X-ray and intravenous pyelography was done in selected cases.
There were 61 males and 89 females with the age range between a new born to 12 years. The most common presenting feature was fever in 78% cases, followed by failure to thrive 58%. vomiting 39% and dysuria 38%. The weight was below the 3rd percentile in 87 children oederna in 13, hypertension 9. tenderness at renal angle in 9 patients and 5 had a distended bladder.
The blood picture showed haemoglobin less than 6 Gm/dl in 27 patients, total leucocyte count more than 15000/mm3 in 22 and an ESR between 5-100mm in 65 cases. Severe proteinuria was encountered in 3 individuals, 13 had casts and 36 had microscopic hacmaturia. The urine culture was positive in 104 children only, with E. coli predominating (58.7%) followed by klebsiclla (4.7%). proteus (3.3%) and pseudomonas (2.7%). All the organisms showed a high sensitivity index to gentamycin, cefatoxime and nitrofuran­tion. Two patients were diagnosed to have bladder stone by plain X-ray abdomen, ultrasonography and intravenous pyelography.
Detection and treatment of UTL is important as it causes troublesome symptoms and increases the risk of vesi­courcternl reflux. Antibiotics should be selected appropriately and administered promptly. To detect vesicoureteral reflux and renal scarring. micturating cystourcthcrogrnphy, ultra­sonography. DMSA and DTPA scan should be performed according to the facilities available in all cases of UTI after three weeks of infection. A suprapubic urine specimen or a catheter sample is necessary for diagnosing UT! especially in infants below 8 weeks of age.
Peiitoncal Lavage - Its Role in Improving Diagnostic Accu­racy of Intra-Abdominal Trauma. Multi, T., Khan, K., Malik, S.A., Mushtaq, T. J. Ayub Med.Coll., 1993;6:14-17.
An accurate diagnosis of internal damage in abdominal t m tuna cases is often difficult. Routi ne diagnostic radiography is usually negative. A CT scan may also not give the desired results. Diagnostic pcritoneal lavage has been more helpful and has replaced the peritoneal tap. The procedure was carried out in 11 patients with abdominal trauma and equivocal signs as local rigidity, haemodynamically unstable patient and significant blood loss with no organ injury. The abdominal wall was cleaned, urinary catheter placed and after instilling a local anaesthetic a small incision made over the linea alba a little below the umbilicus. A sterilized infusion set was used in place of a peritoneal catheter and one liter of normal saline was run in the cavity. The fluid was then allowed to flow out into the attached bag. The peritoncal lavage was considered positive when the fluid was either grossly blood stained, or there was bile or faeces in it, or the hacmoglobin was more than IG/liter, the WBC count more than 500/mm3 or it was turbid. The mean age of these 11 cases was 23.82 years with the male to female ratio being 4.5: 1. The lavage was positive in 8 patients and of these 7 had significant organ damage with involvement of the spleen in 3 cases, liver 1 case, gut perforation in 2 and mesenteric vessel damage in one patient. One case was false positive with no organ damage. There were no false negatives and no subject developed intraperitoncal sepsis or trauma secondaiy to the procedure it was concluded from the study that peritoneal lavage in cases with abdominal trauma provides an accurate pre-op­erative diagnosis without enhancing the risk of infection or organ trauma. Its routine use can avoid unnecessary laparoto­mies.