Tameside Hospital

Abstract Aim Omental Infarction (OI) is a rare cause of Acute abdomen. It occurs in <4 cases per 1000 of Acute appendicitis. We present a case of OI to raise awareness among surgical colleagues of this rare entity and to discuss its management. Case Report 40-year-old male presented to ED with 1 day history of severe and sharp right lower abdominal pain associated with anorexia and nauseous. No bowel or urinary symptoms were reported. On examination he was tender in right lower abdomen with localized guarding and rigidity. Blood investigations revealed WCC of 5.6, Neutrophils of 3.5 and CRP of 9. His lactate and urinary analysis were normal. He underwent CT abdomen and was diagnosed with Omental Infarction. He was managed conservatively with regular analgesics, anti-inflammatory and antiemetics. His symptoms subsided within 5 days and was discharged home with outpatient Follow-up. Discussion As no specific guidelines are available, Surgical fraternity is still debating about the right management strategy for OI. Conservative approach includes treatment with analgesics, anti-inflammatory and antibiotics. Surgical intervention includes laparoscopic omental resection. We Favour the conservative approach with surgical intervention only in case of deterioration. What constitutes deterioration is an individual clinician’s arbitrary judgement. Conclusion OI is a very rare condition; however, it is vital that the surgical colleagues are aware of this condition as timely diagnosis can avoid surgical intervention. It not only saves the patient from unnecessary surgical procedure but also spare already stretched NHS resources.

Abstract Introduction Early Dr*inking, Ea*ting and Mo*bilising (DrEaM) after elective surgery is a fundamental aspect of Enhanced Recovery Programmes (ERPs) to reduces postoperative complications, shorten hospital stay and address surgical backlogs. According to Commissioning for Quality and Innovation (CQUIN) 2023/2024 guidelines, this audit aimed to ensure at least 80% of patients undergoing colorectal surgery were supported to DrEaM within 24 hours postoperatively. Methods A retrospective audit of 176 colorectal resection cases was conducted at a tertiary hospital from July 2023 to December 2024. Patients with incomplete medical or operative notes were excluded. Data was collected in six 3-month cycles, assessing the percentage of patients motivated DrEaM postoperatively and their adherence to these instructions. A plan was made to change the operative note template’s post operative plan to include options for DrEaM after discussion at Clinical Governance meeting and with Executive team. Results Support for drinking was consistently high (94%-100%), with adherence improving from 81% to 100%. Motivation to eat varied (48%-76%), but adherence rose from 51% to 88%. Mobilisation rates showed significant progress, with motivation increasing from 61% to 84% and adherence from 47% to 96%. By the final quarter of 2024, adherence to all DrEaM components exceeded the 80% CQUIN target. Conclusions This audit of 176 patients demonstrates the successful implementation of DrEaM principle in colorectal ERPs, achieving compliance with CQUIN 2023/2024 guidelines. Targeted interventions addressed initial gaps in eating and mobilising, leading to sustained improvements. Early adoption of DrEaM is critical for optimising patient outcomes.

Posterior Reversible Encephalopathy Syndrome is an acute neurological condition characterized by reversible subcortical vasogenic edema, often presenting with seizures, headache, visual disturbances, and altered mental status. Objectives: To evaluate the clinical profile, risk factors, radiological findings, and outcomes of Posterior Reversible Encephalopathy Syndrome patients at a tertiary care hospital in Peshawar. Methods: This prospective cohort study was conducted at Northwest General Hospital and Research Center, Peshawar, from January 2023 to March 2025. Ninety patients diagnosed with Posterior Reversible Encephalopathy Syndrome through clinical presentation and Magnetic Resonance Imaging confirmation were enrolled using non-probability consecutive sampling. Data on demographics, risk factors, symptoms, imaging, outcomes, and length of hospital stay were collected and analyzed. Descriptive analysis of the study was performed through SPSS version 25.0. Results: Among 90 patients, 61 (67.8%) were females, 29 (32.2%) were males. The mean age was 35.92 ± 3.16 years. Seizures (70%), headache (56.7%), and altered mental status (54.4%) were the most common symptoms. Hypertension (53.3%) and postpartum eclampsia (50.8% of females) were the leading risk factors. Magnetic Resonance Imaging showed parieto-occipital/cerebellar involvement in 74.4% and bilateral lesions in 96.7%. Most patients (92.2%) recovered and were discharged, while 7.8% passed away. Conclusions: Posterior Reversible Encephalopathy Syndrome is more prevalent in young females with underlying hypertension or postpartum complications. Early recognition and management can result in favorable outcomes. This study highlights the importance of timely diagnosis to prevent irreversible damage.

Abstract A 16-year-old girl was admitted with complaints of abdominal distension, severe pain, vomiting, chest discomfort, and an inability to pass gas. She disclosed a history of PICA, regularly consuming brick and cement. She had no significant medical history but reported suffering from constipation for over two years. Physical examination revealed a markedly distended, tender abdomen with hyper-resonance. Digital rectal examination detected soft, breakable stool in the rectum. A chest X-ray demonstrated massive bowel distension, causing lung compression. Clinical impression was of bowel obstruction secondary to constipation, leading to NG tube insertion, NBM status, and analgesia administration. A CT abdomen and pelvis confirmed a markedly distended rectum with impacted faeces, proximal faecal loading, and colon dilatation consistent with severe pseudo-obstruction. Other abdominal organs were compressed but otherwise normal, with no signs of ischemia, free air, or free fluid. Patient was taken to emergency theatre for examination under anaesthesia and manual evacuation. Six litres of stool were manually evacuated, along with removal of ingested stone-like substances, leading to suspicion of lithobezoar. This was followed by a four-litre saline washout. Postoperatively, patient received regular enemas, laxatives, and monitoring. She spent three days in the Intensive Care Unit due to persistent metabolic acidosis, necessitating ventilatory support. Afterward, she was transferred to the surgical ward, where she was monitored overnight before being discharged with laxatives and dietary advice. Patient was referred to dietitians for addressing her PICA and eating habits, with plans for psychiatric follow-up initiated through a referral from her GP.

Amyloidosis is a multisystem disease characterized by the extracellular deposition of abnormal protein fibrils in various tissues and organs. It is a systemic disease mainly affecting the kidneys, liver, and spleen. In the GI tract, the duodenum is most commonly involved, followed by the stomach. We came across a relatively unusual case of jejunal amyloidosis, where the presentation was with weight loss, abdominal pain, and changes in bowel habits. Radiological findings were non-specific, such as thickening of small bowel loops and small nodular bowel wall lesions, etc. Endoscopic features were also not characteristic of any particular disease entity. Therefore, it was hard to narrow down the differential diagnosis based on endoscopy and clinic-radiological grounds. The diagnosis remained a mystery until the outcome of the final histopathology report. This case study will facilitate readers in considering this entity in the differential list if they encounter mimicking clinical and/or radiological features.

Undiagnosed phenomena such as long QT syndrome can have devastating effects on patients. Our case, involving a woman in her 30s, highlights the serious effects of undiagnosed long QT and how antiemetic medications can precipitate cardiac events that can lead to fatalities. Various medications are known to prolong QT intervals, and clinicians must be aware of the side effects of some of these commonly used medications. While survival was achieved in this case, education and reflection can act as a tool to help improve global standards of care in this subgroup of the population.

Infective endocarditis (IE) poses a significant clinical challenge due to its non-specific symptoms and variety of complications. Complications can include ischaemic stroke, valve dysfunction, discitis, and osteomyelitis, highlighting the complexity of IE management. We present a case of a male in his 40s, admitted with an ischaemic stroke, eventually being found to have underlying IE with a plethora of complications. This case highlights the importance of collaboration among specialists to form a multidisciplinary team, whichis essential for the effective delivery of care. Furthermore, there is a critical need to explore the psychological impact of IE on patient outcomes, advocating for a holistic approach that considers psychological well-being alongside medical management. Future research should address these underexplored facets to improve patient care and outcomes in IE.

Abstract Background Desmoid fibromatosis, also known as desmoid tumor, is a locally aggressive tumour that develops from fascia and musculoaponeurotic tissue. Chest wall desmoid fibromatoses represent 10-20% of all fibromatoses. Surgery is a successful treatment option for desmoid fibromatosis; however it can be difficult depending on the tumour's location or local spread, and post-resected chest wall reconstruction is becoming a new challenge for surgeons in cases involving ribs. Method we present a rare case of chest wall desmoid fibromatosis involving right sided 9th rib in a 35-year-old male, which was discovered due to a thoracic wall mass. The patient underwent wide tumour surgical excision of the 9th and part of the 10th rib. To reconstruct a neo rib 3D printing of the rib lesion with 1:1 ratio was done in order to obtain a good orientation. Two cannulated cancellous screws were fixed between the two ends of the resected ribs. A simple sternal wire was anchored between the two screws and bone cement was moulded similar to the rib architecture over the sternal wire. Results Post operatively margins were free and lung expansion was satisfactory. 5 year post operative follow up showed no local recurrence. Conclusions This case report sheds light on rare tumour of the rib and provides a comprehensive approach towards its surgical management which includes reconstruction of a neo rib with no major complications. Implications This technique has helped in reconstruction of the chest wall with very limited and easily available resources.