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   Table of Contents - Current issue
January-March 2020
Volume 9 | Issue 1
Page Nos. 1-16

Online since Saturday, March 28, 2020

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The need for routine colonoscopy after acute diverticulitis revisited p. 1
Michelle L Cooper, Cu Tai Lu, Harald Puhalla, Hajir Nabi, Michael Von Papen
Background: The utility of routine outpatient colonoscopy after the conservative management of complicated and uncomplicated colonic diverticulitis has become questionable. Recent literature suggests this time-honored practice after uncomplicated diverticulitis is to be of little benefit, although uncertainty still persists regarding complicated diverticulitis. Objective: We analysed the rates of benign and malignant pathology identified on colonoscopy after conservatively managed uncomplicated and complicated diverticulitis in a hospital where such colonoscopies have been routine practice. Design: A retrospective cohort study was conducted. Setting: Gold Coast Hospital, Southport, Queensland, Australia. Patients and Methods: All patients who were admitted to the Gold Coast Hospital, Southport, Queensland, Australia, between June 2007 and June 2010 diagnosed with acute uncomplicated and complicated diverticulitis were included in the study. The patients were followed up and colonoscopy reports and histology results obtained. Main Outcome Measures: Benign and malignant pathology post uncomplicated and complicated diverticulitis. Sample Size: 144 patients were eligible for inclusion. Results: Between June 2007 and June 2010, 1073 patients were hospitalized with an admission diagnosis coding for diverticulitis. Of these, 144 patients had a computed tomography (CT) which confirmed the diagnosis of acute diverticulitis. Complete colonoscopy and histology data were obtained for 107 of these patients. Of these, 32 patients (29.91%) had pathology found at colonoscopy. One patient (0.9%) was found to have adenocarcinoma of the colon. Conclusion: Colonoscopy follow-up for acute diverticulitis has remained acceptable in many units to exclude alternate colonic pathology. However, recent literature has questioned the utility of this practice. This study – in keeping with this growing body of international literature – found the rate of synchronous/alternative pathology to be comparable to that of asymptomatic patient populations. Routine colonoscopies after uncomplicated colonic diverticulitis confidently diagnosed with a CT scan, therefore, cannot be justified. Limitations: Retrospective nature and sample size. Conflict of Interest: None.
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Is routine pathological analysis of perianal fistula specimen necessary in diagnosis of crohn's disease? p. 7
Steve Y. C Lau, Casey C. H Yu, Suat C Ng, Raaj Chandra
Background: Crohn's disease causes recurrent and complex perianal fistulas. Although the prevalence of it is up to 30%, the common cause of perianal fistula is thought to be the crypto-glandular theory. Surgeons send perianal fistula specimens for histopathological analysis; however, it is unclear whether such practices should be performed routinely. Objective: Evaluating the utility of routine histopathology on perianal fistula specimens during surgery to exclude the diagnosis of Crohn's disease. Design: Multicenter retrospective study was conducted from January 2012 to October 2018 on patients who underwent surgery for perianal fistula and specimen sent for histology. Setting: Metropolitan tertiary referral center in Melbourne, Australia. Patients and Methods: 105 patients who underwent 124 anal fistula procedures and their perianal fistula specimens sent for histopathological analysis were selected from the medical database. Medical and pathology reports were analyzed and data were reviewed by a second author for consistency. Sample Size: 105 patients, 124 procedures. Main Outcome Measures: Histopathological results suspicious for Crohn's disease and endoscopic examination results to confirm Crohn's disease. Results: 41 together, 124 perianal fistula specimens were collected from 105 patients. The male to female ratio was 2.9:1 and the average age was 43.6 years. Nonspecific inflammation was seen in 121 (97.5%) specimens. Three specimens had granulomatous inflammation of which, only two (1.6%) had Crohn's disease confirmed on endoscopic biopsy of the terminal ileum. In 15 patients with Crohn's disease, none of the 19 specimens sent for histology demonstrated histopathological features of Crohn's disease. Conclusion: Routine histopathological analyses of perianal fistula specimens provide limited clinical value. Clinicians should selectively send specimens for histopathological analysis to limit the use of resources. Limitations: Retrospective study. Not all perianal fistula specimens were routinely sent for the analysis. Data prior to 2012 was not collected as we are limited by an electronic database which was commenced in 2012. Conflict of Interest: None.
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Role of local infiltration of methylene blue as an analgesic in stapled hemorrhoidopexy: A prospective study p. 10
Pranav Mandovra, Vishakha Kalikar, Prasang Bajaj, Roy Patankar
Background: Stapled hemorrhoidopexy gained popularity due to low postoperative pain. Few patients still complain of postoperative anal pain. Methylene blue (MB) in caudal and epidural anesthesia gives long-term pain relief and has also been used to treat intractable pruritus ani. Objective: Evaluate the role of local infiltration of the MB as an analgesic in the procedure for prolapse and hemorrhoids (PPH) surgery. Design: Prospective observational study. Setting: Tertiary health care center. Patients and Methods: Patients with grade-III hemorrhoids were included and were divided into two groups: A and B. Group A received a perianal injection of 2 mL of 1% MB with 10 mL of 25% bupivacaine. Group B received a perianal injection of 2 mL of normal saline with 10 mL of 25% bupivacaine. Main Outcome Measures: Patients were followed up prospectively for pain, hospital stay, and complications. Results were noted and compared between the two groups. Sample Size: 50 patients. Results: Group A had significantly lower pain scores on day 3 (mean ± SD 2.08 ± 1.08) and day 7 (mean ± SD 0.64 ± 0.95) as compared to the pain scores on day 3 (mean ± SD 3.92 ± 1.35) (P-value = 0.000) and day 7 (mean ± SD 2.40 ± 1.0) (P-value = 0.000) in group B. Pain scores within first 24 h and day 21 post-surgery were not statistically significant between groups A and B (P-value = 0.286 and 0.19, respectively). Group B required a significantly higher number of both injectable and oral analgesics (mean + SD 4.03 + 0.94) as compared to group A patients (mean + SD 1.97 + 0.81) (P-value = 0.001). 4% of the patients in group B had prolonged hospital stay due to severe pain. Patients in group A also had a significant reduction in their requirement of analgesics. None of the patients who received MB had any local or systemic allergic reactions. Conclusion: Local infiltration of MB may be used as an effective analgesic in PPH patients without any increase in morbidity. Limitations: Single-center study with a small sample size. Conflict of Interest: None.
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Granular cell tumor of the colon presenting as profound weight loss p. 14
Sarah E Diaz, Jon M Hain, Sarah D Hans
Granular cell tumors (GCTs) are typically benign tumors of neuronal origin that stain positive for S-100. They traditionally occur in the skin and subcutaneous tissue with gastrointestinal tumor sites, such as the colon, being rare. On colonoscopy, they appear as a well-circumscribed, yellow, submucosal lesion. Biopsy prior to endoscopic or surgical removal can be inconclusive due to the submucosal nature of the lesion. Although GCTs are rarely malignant, they can metastasize with a high mortality rate. Endoscopic resection has been described as an appropriate treatment for tumors up to 5 cm in diameter. We present the case of a 19-year-old male who experienced a 60-pound weight loss, which was initially attributed to depression. On clinical examination, a GCT was found in his ascending colon.
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