40 year-old Man With Difficulty In Swallowing

Mr. J, a 40 years old Malay gentle man was referred from JB hospital for suspected Achalasia Cardia. He was previously well until 9 months ago, he started to experience constant difficulty in swallowing his food particularly solid food. This was also associated with increased burping and regurgitation of food particles after eating. There was  significant loss of weight as a result of poor feeding. Mr. J however, denied  history  of loss in appetite, pain while swallowing, vomiting of blood and passing out black colored stools. Past medical history and family history of malignancy were not significant.

Q1 What are the differential diagnosis do you have in mind?

 

Q2: What are the investigations to confirm your diagnosis?

72 year-old Lady With Lower Abdominal Pain And Rectal Bleeding

A 72 year old lady presented with a three month history of colicky lower abdominal pain and rectal bleeding. Rectal and sigmoidoscopic examinations were unremarkable. A barium enema was requested. This image is from a barium enema series. 

How do you describe the radiological finding? What is the diagnosis?

Suture Training Workshop 1

Our very first Suture Training Workshop had just passed ! The event was held in SR 10  at 5.00pm until 7.00pm . The event was opened to 20 members . The participants consisted of members from Semester 6 , Semester 7 and Semester 9 . 

During the Suture Training Workshop , each participants were provided a piece of chicken skin , and a set of surgical instruments. We focused on the basic suture techniques in this session as it is the most fundamental skills we needed to master. 

Participants  filled up SR10 .

Everybody was excited and eager to learn the suture & knotting techniques . 

Committee members helped participants settle down and ensured everyone had a complete set of materials before the workshop started . 

A video was played . Participants learnt and revised their techniques through the video .

After the video was played , participants tried the 2 hands and 1 hand technique of knotting. 

Committee members provide one-on-one guidance to participants. 

By Cheah Yue Yi Semester 6

By Kevin Wong Semester 6

By Yee Pui Mun Semester 6

by Kok Wooi Semester 6

By Eldwin Oui Semester 7

By Elvina Semester 7

By Niki 

By Kong Xin Yi Semester 6

By Lo Vee-Shin Semester 9

By Tan Jian Ming Semester 9

By Chai Siew Ting Semester 9

By David Chieng Semester 9

By Grace Ng Semester 6

WHO DO YOU THINK HAS THE BEST CONTINUOUS / INTERRUPTED SUTURE ?

Predicting Mortality in Acute Pancreatitis

Acute pancreatitis is defined as sudden inflammation of the pancreas with no or little fibrosis. It can be further categorized based on its severity- edematous pancreatitis, or necrotizing pancreatitis. 

The identification of the severity of pancreatitis is vital as any delayed management could result in serious complication and death. Various score systems such as the Modified Glasgow criteria, Ranson’s criteria and (APACHE) II have been used to predict the prognosis for acute pancreatitis. 

The news below shows a new and simple scoring system for acute pancreatitis. Have fun reading it!

Simple Tool May Help Predict Mortality in Acute Pancreatitis

Laurie Barclay, MD  

January 13, 2009 — A new mortality-based prognostic scoring system for use in acute pancreatitis may help identify patients at increased risk for in-hospital mortality, according to the results of a large, population-based study reported in the January issue of Gut.

"Identification of patients at risk for mortality early in the course of acute pancreatitis (AP) is an important step in improving outcome," write Dr. B.U. Wu, from Brigham and Women's Hospital and Harvard Medical School in Boston, Massachusetts, and colleagues. "Current methods of risk stratification in AP have important limitations."

The goal of the study was to develop a simple and accurate clinical scoring system that would classify patients with acute pancreatitis based on their risk for in-hospital mortality, with use of Classification and Regression Tree analysis. Data from 17,992 cases of acute pancreatitis from 212 hospitals from 2000 to 2001 were used to derive the scoring system, and data from 18,256 cases of acute pancreatitis from 177 hospitals in 2004 to 2005 were used to validate the new scoring system.

The area under the receiver operating characteristic curve allowed determination of the accuracy of the scoring system to predict mortality. By comparing predictive accuracy of the new scoring system vs Acute Physiology and Chronic Health Examination (APACHE) II, performance of the new tool was further validated.

Based on Classification and Regression Tree analysis, there were 5 variables identified that predicted in-hospital mortality, each of which was assigned 1 point if present during the first 24 hours: blood urea nitrogen more than 25 mg/dL, impaired mental status, systemic inflammatory response syndrome, age older than 60 years, or pleural effusion (BISAP). Mortality rates ranged from less than 1% in the lowest-risk group to more than 20% in the highest-risk group. BISAP receiver operating characteristic curve was 0.82 (95% confidence interval, 0.79 - 0.84) in the validation cohort vs an APACHE II receiver operating characteristic curve of 0.83 (95% confidence interval, 0.80 - 0.85).

"A new mortality-based prognostic scoring system for use in AP has been derived and validated," the study authors write. "The BISAP is a simple and accurate method for the early identification of patients at increased risk for in-hospital mortality."

Limitations of the study include subjective assessment of mental status; differences between the validation cohort and the derivation cohort; and reliance on International Classification of Diseases, Ninth Revision, data for diagnosis.

"The BISAP score stratifies patients within the first 24 h of admission according to their risk of in-hospital mortality and was able to identify patients at increased risk of mortality prior to the onset of organ failure," the study authors conclude. "The ability to risk-stratify patients early in their course is a major step to improving future management strategies in acute pancreatitis."

In an accompanying commentary, Peter Layer, MD, PhD, from Israelitic Hospital in Hamburg, Germany, notes that although none of the predictive variables were truly surprising, this study should be considered a "significant contribution."

"This new index offers an attractive extension of our diagnostic armamentarium in acute pancreatitis," Dr. Layer writes. "On first glance its main appeal appears to be its easy practicability. However, provided the reported respectable accuracy rates can be confirmed elsewhere, it may be expected that such an uncomplicated, quick and reasonably reliable assessment of disease severity on admission could gain broad acceptance in routine use, not by replacing clinical assessment (which will maintain its indisputable prominence), but rather by complementing and objectifying it."

The study authors and Dr. Layer have disclosed no relevant financial relationships.

Source: Gut. 2009;57:1645-1646, 1698-1703

Rectal Metastasis From Breast Cancer: An Interval of 17 Years

Breast cancer is the most frequently diagnosed life-threatening cancer in women and the leading cause of cancer death among women . The most common first site of distant spread for breast cancer was bone (51%), followed by lung (17%), brain (16%), and liver (6%). The remaining 10% of patients had multiple metastatic sites. A case report done in 2011 by Aliasger A Amin et al , showed metastasis of lobular carcinoma to the rectum . Read on to find out more details on the case !

Rectal metastasis from breast cancer: an interval of 17 years

Summary

Metastasis to gastrointestinal (GI) tract from breast cancer is rare. Commonly affected organ in GI tract is stomach, followed by colon and then rectum. The authors report a case of a 61-year-old woman who had a mastectomy for lobular carcinoma of the breast 17 years ago and was referred to colorectal clinic with increased frequency of stools. Colonoscopy showed a stricture in the rectum, but biopsy was inconclusive. As she was symptomatic, she had a Hartmann’s resection 5 months after she initially presented to the clinic. Histopathology of the resected specimen showed it to be metastasis from lobular carcinoma of the breast. Awareness of potential long delays in the presentation of metastatic breast cancer especially lobular carcinoma helps in the earlier diagnosis and clinical management.

Background

Metastasis to gastrointestinal (GI) tract from breast cancer is rare. Awareness of potential delays in the presentation of metastatic breast cancer especially lobular carcinoma helps in the earlier diagnosis and clinical management.

Case presentation

A 61-year-old woman presented to the clinic with a 3-month history of change in bowel habits, that is, loose stools (6–20 times/day) and faecal urgency following a holiday. There was no history of bleeding, mucous discharge per rectum or associated bowel symptoms. Her medical history included recurrent deep venous thrombosis (life long warfarin) and a right-sided mastectomy 17 years ago for lobular breast cancer with negative axillary lymph nodes and had tamoxifen for 5 years. Colonoscopy showed a circumferential smooth stricturing lesion in the rectum (10 cm from anal verge). Biopsy results from this abnormal area were inconclusive. She was diagnosed as possible gastroenteritis/colitis and was managed conservatively. CT and MR scan showed mucosal thickening involving the whole rectum, with preservation of mural structures, showing no suggestions of malignancy. She became gradually more symptomatic with the stricture in the rectum, and went on to have a Hartmann’s resection (delay of 5 months).

Investigations

Histopathology of the resected specimen showed it to be a metastatic lobular carcinoma from the breast. On immunohistochemical staining, the tumour cells were negative for cytokeratin (CK) 20 but showed strong and diffuse positive staining for oestrogen receptor and CK7 and weak patchy staining for progesterone receptor. This immunoprofile was in keeping with metastatic lobular carcinoma of breast. She went on to have a staging CT scan which showed at least two metastatic lymph nodes in the axillary region. Core biopsy of the axillary lymph node confirmed malignancy. 

Histology slide showing normalrectal mucosa and breast cancer

Treatment

She had a right-sided axillary node clearance. Nodes were oestrogen receptor positive but negative for HER 2. She had adjuvant letrozole.

Learning points

▶ Carcinoma of the breast has a potential to metastasize to gastrointestinal tract, more commonly, lobular carcinoma of the breast.

▶ Metastasis to the gastrointestinal tract from breast cancer can occur many years after the initial primary.

▶ We should be aware that presenting symptoms of a metastatic breast cancer to the rectum can be non-specific and difficult to diagnose even on endoscopic biopsy.

▶ A thorough approach is required to diagnose a rectal metastasis from a breast carcinoma in the form of radiological studies, endoscopy and biopsy.

▶ It is important to be aware of such an occurrence and a high degree of suspicion is required; since early diagnosis can enable us to start systemic therapy before a complication sets in, avoiding unnecessary surgery and improving outcome.

References/ Sources : 

1.Reference:Patanaphan V, Salazar OM, Risco RBreast cancer: metastatic patterns and their prognosis. Southern Medical Journal [1988, 81(9):1109-12]

2.Aliasger A Amin, Anil Reddy, Madan Jha, P Kolanu .Rectal metastasisfrom breast cancer: an interval of 17 years [Internet] 2011 BMJ Case Report. Available from : http://casereports.bmj.com/content/2011/bcr.01.2011.3683.abstract

Suture Training Workshop

Here's your chance to put your knowledge into practice dear friends ! 

Diets High In Fiber Won't Protect Against Diverticulosis

Source :  Link for IMU students / [Abstract]

2012 FEB 12 - (VerticalNews.com) -- CHAPEL HILL, N.C. - For more than 40 years, scientists and physicians have thought eating a high-fiber diet lowered a person's risk of diverticulosis, a disease of the large intestine in which pouches develop in the colon wall. A new study of more than 2,000 people reveals the opposite may be true.

The study, conducted by researchers at the University of North Carolina at Chapel Hill School of Medicine , found that consuming a diet high in fiber raised, rather than lowered, the risk of developing diverticulosis. The findings also counter the commonly-held belief that constipation increases a person's risk of the disease.

"Despite the significant morbidity and mortality of symptomatic diverticulosis, it looks like we may have been wrong, for decades, about why diverticula actually form," said Anne Peery, MD, a fellow in the gastroenterology and hepatology division at UNC and the study's lead researcher. The study appears in the February 2012 issue of the journal Gastroenterology.

"While it is too early to tell patients what to do differently, these results are exciting for researchers," said Peery. "Figuring out that we don't know something gives us the opportunity to look at disease processes in new ways."

Diverticulosis affects about one-third of adults over age 60 in the United States. Although most cases are asymptomatic, when complications develop they can be severe, resulting in infections, bleeding, intestinal perforations and even death. Health care associated with such complications costs an estimated $2.5 billion per year.

Since the late 1960s, doctors have recommended a high-fiber diet to regulate bowel movements and reduce the risk of diverticulosis. This recommendation is based on the idea that a low fiber diet will cause constipation and in turn generate diverticula as a result of increased pressure in the colon. However, few studies have been conducted to back up that assumption. "Our findings dispute commonly-held beliefs because asymptomatic diverticulosis has never been rigorously studied," said Peery.

The UNC study is based on data from 2,104 patients aged 30-80 years who underwent outpatient colonoscopy at UNC Hospitals from 1998-2010. Participants were interviewed about their diet, bowel movements and level of physical activity.

"We were surprised to find that a low-fiber diet was not associated with a higher prevalence of asymptomatic diverticulosis," said Peery. In fact, the study found those with the lowest fiber intake were 30 percent less likely to develop diverticula than those with the highest fiber intake.

The study also found constipation was not a risk factor and that having more frequent bowel movements actually increased a person's risk. Compared to those with fewer than seven bowel movements per week, individuals with more than 15 bowel movements per week were 70 percent more likely to develop diverticulosis.

The study found no association between diverticulosis and physical inactivity, intake of fat, or intake of red meat. The disease's causes remain unknown, but the researchers believe gut flora may play a role.

Peery said more research is needed before doctors change dietary recommendations, but the study offers valuable insights on diverticulosis risk factors. "At this time, we cannot predict who will develop a complication, but if we can better understand why asymptomatic diverticula form we can potentially reduce the population at risk for symptomatic disease," said Peery.

Case-Based Discussion: An introduction to the benefits and its approach

Hello dear friends ! Case-based disccusions(CBD) are one of the activities we will be having throughout each semester . As the name of the activity suggest, CBD is a session where members of the society come together to discuss about the cases that we encountered in the wards. These sessions would be a platform to learn and improve our knowledge , presentation skills  and critical thinking skills.

In short , students will be selecting and presenting cases according to the theme of our month . These cases will be published on the blog. During the session, students will determine and generate learning issues. They will be divided into small groups for discussion. Representatives from the group will then present on the results  of their discussion. Queries and doubts during the session would be relayed to our lecturers and the answers would be published on the blog.

Each CBD is opened to 25 members.The session is a student-centered discussion. We may involve housemen , medical officers and lecturers to supervise us in our discussions if the first few discussions went well. 

Below is a detailed description of how the case-base discussion will be conducted.

CASE-BASED DISCUSSION

What are the aims and objectives?

1. To improve presentation and communication skills 
2. To revise the basic anatomy and physiology of human body in relation to a particular disease 
3. To encourage critical and analytic thinking skills 
4. To encourage Self-directed learning 

What students should do before attending the case based discussion session?

1. Students are encouraged to submit their case to present during the session 
2. Students will be notified via face book group page for any update of the case discussion session  
3. Cases will be posted on the IMU surgical society blog (IMUSURGICALSOCIETY.BLOGSPOT.COM)
4. Students are expected to do some basic study before attending the case based discussion session 
5. 25 places will be opened for each session

How will the case based discussion class be conducted?

Case submission is opened to all students. Fields of discussion include all surgical specialties.

Requirements:
1. Precise, clear and detail history taking.
a. Preferably complete cases ( from day 1 of admission until discharge )

2. Complete physical examination 

3. Complete day to day plan and the management of the patients
a. This includes investigations, drugs given, operative management, pre- operative and post-operative assessment, intra-operative finding.

4. Identify and prioritize the problems

a. What was the complaint, has it been issued out?

E.g.: Mr. X. 46 years old Indian, with family history of colorectal Ca presented with altered bowel movement for the past 6 weeks and alternate pr bleeding for the past 3 days. Physical examination noted mass over the right iliac fossa. Subsequent diagnosis of Caecal Ca was given.
What could have been done? When is the bowel Ca screening appropriate for one with family history of the similar problem?
(Information is to be quoted from books, preferably journal) 

b. What else can be done to benefit the patients?

c. Medication. ( Avoid using brand name but drug name instead)

5.  Revisit and revise physiology, anatomy, pathophysiology and management of the disease. Application of knowledge according to the case is important. Information used should be quoted.

6. Case summary will be posted on blog on the first / second day of each week.

7. During the session, case summaries are to be presented. Other participants are encouraged to post up questions and doubts. Learning issues will be identified throughout the discussion
a. This session is solely student-interactive based and students are encouraged to present and learn from their mistakes through constructive advices.

b. Hand to be raised before answering or proposing questions

8.   Participants will be divided into 4 to 5 small groups to present each learning issue.

a. How does the anatomical structures affect the surgical procedure?

E.g.: Caecal Ca is treated by right hemicolectomy with primary anastomosis. Which and why that particular blood supply is cut? Why is right sided Ca more likely to be asymptomatic than left sided Ca?

b. Epidemiology, etiology of the disease in relation to the case

E.g.: MR. X is only 46 but diagnosed with colon CA. Why? What is the Etiology? How is his diet? Is he a smoker? Was there previous cholecsystecomy? Was there any previous irradiation? How about family history?

Based on discussion, we conclude that MR. X’s disease is due to sporadic mutation of gene. What gene mutation is involved? What is the percentage of sporadic changes?

c. Investigations in relation to the particular case

d. Management

* Each small group will have 2 representatives during the presentation.

9. Identify what have the students learnt or benefit from the session. 

10. Compile questions and seek for lecturer’s advice. All answers will be posted on the blog.

*Any explanation or answer is best to be quoted from books or journal.

Kindly contact anyone of us if you are interested in submitting cases or attending the session: 

Sem 9 rep : Goh Chon Han Robin gch_1988@hotmail.com 010-2215270
Sem 8 rep : Koh Pei Fern kohpeifern@yahoo.com 012-3872812
Sem 7 rep : Lee Wei Rong e.alvin_wrlee@hotmail.com 017-5557125

Vote For Your IMU Surgical Society Logo

As all of us know , IMU Surgical Society is the new "kid" on the block , we are in the midst of designing a logo for our society. We would like to involve every member in the selection of our society logo . We had came up with these logos . Feel free to give your comments or, better yet, help us design our logo!

Your feedbacks are highly appreciated.

Also , throw in your votes for your favorite logos at the end of the blog post!

Logo 1

Logo2

Logo3

Logo4

Logo5

Which logo do you like ?

4th Undergraduate Surgical Conference 2012

For further details , please refer to their facebook page and webpage. 

If interested , please contact your batch reps.

Its Official !!

29th March 2012 marks a memorable day in history . Mark your calendars dear friends for this was the day IMU Surgical Society (ISS) was officially launched !

The launching ceremony commenced at 12.30pm sharp.

Mei Han , vice president and our MC for the day.

Look at all the people ! 

We were awestruck (in someways shocked) by the number of students who turned up that day. 

Eric , our president giving his speech  

Prof.Lum, lauching the society. 

Hareez , Daniel Eh , Prof Lum , Dato Kanda and Eric

Dato Kanda talking to us about the history of surgery in Malaysia. 

We would also like to thank Prof Lionel , Dr.Ranjan , Prof Yushak and Prof Kareem  for their support and time . 

Lunch was provided after the launching ceremony in SR1 & SR2

Fellow friends enjoying their Nasi Lemak.

All in all , the launching ceremony went smooth. None of this would have materialized if not for everyone who was present.

Words cannot express our heartfelt gratitude for the time and support from everyone who was at the John Bosco Lecture Theater that afternoon. We especially want to thank Dato Kanda , Prof Lum , our dearest lecturers , IMU Clinical Skills Unit sisters and IMU staff for sparing some time for the event .

May our passion for surgery continue to burn as we come together to learn and to serve !