An unusual cause of acute abdomen and acute renal failure: Djenkolism

The djenkol bean (Archidendron pauciflorum) is a native delicacy in Southeast Asia, though consumption can sometimes lead to djenkolism. Clinical features of djenkolism include acute abdominal pain, hematuria, urinary retention, and acute kidney injury (AKI). The pain can be severe, which often leads to a misdiagnosis of acute abdomen. In this paper, we report the case of an Indonesian migrant with djenkolism. Due to the short history and severity of the abdominal pain, medical professionals suspected acute abdomen and proceeded with a negative exploratory laparotomy. However, djenkolism was suspected once relatives informed the professionals that the patient had consumed djenkol beans hours earlier. The patient recovered through aggressive hydration and urine alkalinization with bicarbonate infusion. We highlight the importance of being aware of this rare cause of AKI, especially in Southeast Asia, in order to provide early diagnoses and prompt treatments.

AWARENESS, KNOWLEDGE LEVEL, AND MISCONCEPTIONS ABOUT SEXUALLY TRANSMITTED INFECTIONS AMONG SECONDARY SCHOOL STUDENTS IN BRUNEI DARUSSALAM

Sexually transmitted infections (STI) remain an important public health issue globally, particularly among the young population. Despite being preventable and curable, STI continue to spread. Lack of access to treatment is an important factor in many developing and underdeveloped nations. Lack of awareness and knowledge is another important factor. This study assessed the awareness, knowledge, and misconceptions among secondary school students on STI. Overall, awareness was poor but better among male students and those in the Pure Science academic streaming. Similarly, the knowledge level of STI was also poor: low level (63.0%), moderate level (34.4%), and high level (2.6%). Male students (p=0.014) and Pure Science academic streaming students (p<0.001) scored better. There were misconceptions, but poor knowledge was predominant. Common sources of information were teachers, health professionals, Internet, parents and TV programs. Based on our study, more needs to be done to improve the awareness and knowledge level of STI, and detailed inclusion into the educational curriculum may be a consideration.

Choledochal cyst in pregnancy

INTRODUCTION

Biliary diseases during pregnancy are not uncommon and are frequently due to cholelithiasis. Choledochal cyst during pregnancy is rare. The management of biliary pathologies during pregnancy poses a challenge as the window of opportunity to carry out any interventions with minimal risk is small.

CASE REPORT

We report the case of a lady who was diagnosed with a large type I choledochal cyst during the second trimester of pregnancy. Due to increasing symptoms and recurrent cholangitis, she was managed with antibiotics and surgical resection. She remained well and delivered a healthy baby boy.

CONCLUSION

Clinicians need to consider choledochal cyst as a differential in pregnant patients presenting with upper abdominal fullness.

Ectopic inferior vena cava thrombus secondary to a tubo-ovarian abscess

Inferior vena cava (IVC) thrombosis typically arises distally from a thrombophlebitic extension in the pelvis or the lower extremities. It may also occur from propagation of an ovarian vein thrombosis as a result of gynaecological disorders such as pelvic inflammatory disease, endometritis or from pelvic surgeries. In this report, we present an interesting case of a tubo-ovarian abscess with an ectopic IVC thrombus. The approach to management in such cases is also highlighted.

Gastro-oesophageal reflux disorders among Nepalese residing in Southeast Asia

INTRODUCTION

Gastro-oesophageal reflux disorders (GORD) are common in Western countries and has been reported to be increasing in the East. This study assessed the prevalence of GORD among the Nepalese residing in the Brunei Darussalam.

METHODS

Nepalese residing in two areas were invited to participate in this cross sectional questionnaire study. GORD was considered to be present if there was any heartburn, regurgitation or both experienced at least monthly that were associated with impairment of quality of life measures. Overall, 304 out of 320 (female 68.4%) with completed questionnaire were available for analysis.

RESULTS

Overall 45.1% had reported symptoms of gastroesophageal reflux: heartburn and regurgitation (21.4%), heartburn alone (9.2%) and regurgitations alone (14.5%). However, only 7.2% had GORD. GORD was significantly more common among women (p=0.005), being shorter in height (p=0.013), those with co morbid conditions (p=0.023) and previously had endoscopy (p=0.006). There were no difference in age, duration of residence, body mass index (kg/m2), alcohol intake, tobacco and supplements use (all p>0.05). GORD was also significantly associated with the presence of psychosomatic symptoms such as backache, depression, fatigue, headache and insomnia (all p<0.05). Subjects with GORD also experienced significantly more other upper gastrointestinal complaints such as nausea, vomiting, early satiety, post-prandial fullness, and abdominal bloating (all p<0.05).

CONCLUSIONS

The prevalence of GORD among Nepalese residing in Brunei Darussalam was 7.2%. Certain subjects' profiles were associated with GORD and patients with GORD were likely to experience more psychosomatic and other gastrointestinal symptoms.

A rare case of Dysphagia secondary to a large oesophageal lipoma

Dysphagia is considered a warning symptom that requires exclusion of significant pathology such as oesophageal cancer, especially in elderly patients. Benign neoplasms of the oesophagus are rare. We report the case of a 69-year-old lady who presented with a five years history of infrequent intermittent dysphagia that had rapidly progressed over one month. This was associated with globus sensation, weight loss, intermittent episodes of stridor and aspiration pneumonia. Investigations revealed a large oesophageal lipoma in the proximal oesophagus extending down to the lower oesophagus. This was successfully resected via a left cervical approach. She remained well two years after the surgery.

Differences in patient profiles of abdominal and pulmonary tuberculosis: a comparative study

OBJECTIVES

Tuberculosis remains a common infection and is often associated with non-specific constitutional symptoms or laboratory investigations regardless of site of manifestations. This study compares the profiles of abdominal tuberculosis (ATB) and pulmonary tuberculosis (PTB).

METHODS

Patients with ATB (n=34, male-21, mean age 43.3 +/- 16.0 years) diagnosed over a nine year period were identified from the National Tuberculosis registry and retrospectively reviewed. Comparisons were made with patients treated for PTB (n=163).

RESULTS

The most commonly affected sites were the ileocecal regions, peritoneum and hepatobiliary system. Common clinical presentations were abdominal pain (61.8%), anorexia (44.1%), weight loss (55.9%), fever (41.1%) and abdominal distension (29.4%). Four patients had concomitant active PTB. Compared to PTB, patients with ATB had significantly lower serum haemoglobin (11.6 +/- 2.4 vs. 12.6 +/- 2.0 gm/dL, p=0.036) and higher rate of adverse events of antituberculous treatment (50% vs. 15.4%, p < 0.001). There were no difference in prevalence of constitutional symptoms (fever, weight loss and anorexia), platelet level, albumin, total protein and erythrocyte sedimentation rate. Importantly, there was no difference in the treatment response. More patients with ATB and concomitant active PTB had reported weight loss (100% versus 36.7%, p = 0.017).

CONCLUSION

There are differences in the profiles of ATB and PTB. Awareness of such differences can help to improve the understanding and management of this infection.

Cytomegalovirus colitis in immunocompetent patients

Cytomegalovirus (CMV) infection can present with severe manifestations that are associated with significant morbidity and mortality, especially in immunocompromised patients. CMV infections in immunocompetent patients are usually transient and do not exhibit many symptoms. However, in some patients, the manifestations can be severe. We report CMV colitis in two immunocompetent patients; one in a young man who was critically ill with septicaemia and significant non-bloody diarrhoea that responded to specific CMV treatment, and another in an elderly woman who presented with nonspecific abdominal pain and fever that resolved without specific CMV treatment.

Massive lower gastrointestinal bleeding secondary to colonic mucormycosis

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.

Tuberculous appendix: a review of clinical presentations and outcomes

INTRODUCTION

Tuberculous appendix is surprisingly rare, even in countries where this infection is common. We report our experience with tuberculous appendix over a 15-year period.

METHODS

A search for cases of tuberculous appendix was conducted from January 1995 to December 2009 on the databases of the National Tuberculosis Centre and the Departments of Pathology and Surgery of Raja Isteri Pengiran Anak Saleha Hospital.

RESULTS

There were five cases of tuberculous appendix, giving a cumulative incidence of 0.08 percent of all appendectomies (n is 6,593), 0.2 percent of tuberculosis (TB) cases (n is 2,876) and 8.6 percent of abdominal TB (n is 58). Three patients were male and two were female, with a median age of 27 (range 25-48) years. Four patients presented with symptoms of acute appendicitis and one with an appendiceal mass following treatment for acute gastroenteritis. Only one patient had constitutional symptoms. Four patients had appendectomies (one laparoscopic and three open) within the same admission and one had interval appendectomy. Operative findings included perforated appendix (n is 1), appendiceal mass (n is 1) and acute appendicitis (n is 3). In all cases, the diagnoses were made only after review of the histology. None of the patients had pulmonary TB. Delay in initiating anti-TB treatment in one patient resulted in the development of an ileocutaneous fistula following appendectomy. This was resolved by excision, followed by anti-TB treatment.

CONCLUSION

Tuberculous appendix can present as acute appendicitis, and the diagnosis is often made after surgery. Any delay in treatment can lead to significant complications.

Autoimmune hepatitis in children: a report of two cases

In regions where chronic hepatitis B infections are still endemic, autoimmune hepatitis (AIH) is considered rare, and it is even rarer in the paediatric population. AIH in the paediatric population is categorised into type 1 and 2, which are differentiated by their autoantibody profiles. We present two cases of paediatric type 1 AIH. Two girls aged 11 and 15 years were referred to our hospital with chronic liver disease, one of whom had decompensated disease. Both patients were started on prednisolone. The patient with advanced liver disease died from complications due to infections that included the pandemic novel influenza A H1N1, while the other patient responded to treatment. These two cases serve to highlight the importance of considering AIH in any paediatric patient presenting with features of chronic liver disease, as the response to treatment is good.

Autoimmune thyroiditis and delayed onset psoriasis in association with combination therapy for chronic hepatitis C infection

A combination of pegylated interferon and ribavarin is currently the gold standard for the treatment of chronic hepatitis C infection. Interferon therapy can lead to the development of an autoimmune phenomenon that can be sub-clinical or clinical, and the presence of autoantibodies increases the risk. Thyroiditis is the most common autoimmune manifestation of interferon therapy and can present during treatment or after the completion of treatment. On the other hand, psoriasis is rare, and has been reported to occur within weeks of starting the treatment. We report a case of a 46-year-old indigen woman who was positive for multiple autoantibodies, and developed autoimmune thyroiditis that manifested as hypothyroidism during pegylated interferon and ribavarin therapy for chronic hepatitis C infection. She also developed plaque psoriasis after the completion of therapy. In our case, the association with thyroiditis was definite, whereas that with psoriasis was less definite. However, it is still important for clinicians to be aware of such rare associations.

Spontaneous intramural duodenal haematoma with transient biliary obstruction and acute cholecystitis

Intramural duodenal haematoma (IDH) is uncommon and usually presents with upper gastrointestinal bleeding. Trauma, anticoagulant therapy, blood coagulation disorders and endoscopic interventions have been reported to cause IDH. IDH secondary to antiplatelet therapy has not been previously reported in the literature. We report IDH secondary to aspirin therapy that was associated with transient obstructive jaundice and acute cholecystitis in a 47-year-old woman. The patient was successfully managed with conservative management.

Triple synchronous gastrointestinal malignancies: a rare occurrence

Gastrointestinal cancer is common, and is a significant cause of morbidity and mortality. The synchronous occurrence of two different malignancies is not uncommon, but that of more than two malignancies is extremely rare. Such occurrences often pose diagnostic and therapeutic challenges. We report the case of an elderly man who was previously treated for gastric cancer 13 years ago, and who was later diagnosed with synchronous triple gastrointestinal malignancies consisting of hepatocellular carcinoma, a gastric collision tumour with adenocarcinoma and a large B cell lymphoma. The patient's condition progressed rapidly, and he died four weeks after the diagnosis.

Rare complications of pyogenic liver abscess

Pyogenic liver abscess (PLA) is still associated with significant morbidity and mortality. With advances in imaging, most cases are now diagnosed early and effectively treated. However, complications, although considered rare, may still occur. We report three cases of PLA that were associated with rare and significant complications. Two patients had an abscess rupture that resulted in pyopericardium in one patient and sub-diaphragmatic abscess in the other. Another patient with Klebsiella pneumoniae PLA had bilateral endophthalmitis that resulted in blindness. Death secondary to overwhelming sepsis occurred in the patient with Escherichia coli-related pyopericardium. Delay in diagnosis contributed to the complications in two of the patients.

Hepatobiliary tuberculosis

Tuberculosis (TB) infection is still common today and remains an important cause of morbidity and mortality. Abdominal TB is one of the most prevalent forms of extrapulmonary manifestations, and collectively refers to gastrointestinal, splenic, pancreatic, hepatobiliary and abdominal lymphadenopathy involvement. The manifestation can be nonspecific, and mimics many conditions, including malignancies. Biliary involvement is extremely rare. It can directly involve or be a result of external compressions or extension from adjacent organs. Strictures can be simple or multiple and isolated or complex. Radiologically, it is difficult to exclude cholangiocarcinoma. Hepatic involvement is more common and is categorised as the miliary or isolated local type. Both can be further sub-divided into nodular or diffuse forms. The manifestations range from abscesses and tuberculomas to hepatic calcifications. Calcifications range from small isolated specks to gross calcification with or without hepatic atrophy. The diagnosis of hepatobiliary TB (HBTB) can be difficult. Ultrasonography and computed tomography are the main radiological investigations. Endoscopic retrograde cholangiography is important in the management of biliary TB. It is often important to look for the involvement of other organs and consider the coexistence of other pathologies such as malignancies. This pictorial essay reviews some of the HBTB infections that have been encountered in our tertiary referral centre.

Elevated serum CA 19-9 in association with Hashimoto thyroiditis

Tumour markers are widely used in clinical practice. Elevated tumour markers can be observed in both malignant and benign conditions. Therefore, it is important for clinicians to be aware of the association of tumour markers with various disorders so that unnecessary investigations can be avoided without missing the malignant disorders. A 58-year-old woman who presented with weight loss and elevated carbohydrate antigen 19-9 (CA19-9) was referred to our hospital for evaluation and was subsequently diagnosed with Hashimoto thyroiditis. Investigations for underlying malignancy were negative. The CA19-9 level normalised subsequently, with restoration of the euthyroid state.

An indolent diffuse infiltrating gastric carcinoma

Gastric cancer is a common gastrointestinal cancer and is an important cause of cancer mortality. Unfortunately, it is often diagnosed late due to delayed presentation. We report the case of a 48-year-old man who was diagnosed with diffuse infiltrating gastric adenocarcinoma and who had initially declined surgery. The patient presented again the following year, and the repeat evaluations showed similar findings. Despite this, the patient continued to decline interventions. Six years later, as his symptoms increased, the patient finally underwent surgery. Histology revealed a diffuse infiltrating stage T3 tumour, with significant desmoplastic reaction and negative lymphadenopathies. Seven years after the surgery, the patient remained well and recurrence-free. This case highlights that some cancers have an indolent course, and even with significant delay, curative interventions can still be performed.

Tuberculous aorto-duodenal fistula: a rare cause of upper gastrointestinal bleeding

Aorto-enteric fistulas are rare and are associated with significant mortality. Infective causes usually occur within the setting of post-graft repair. Aorto-enteric fistula secondary to tuberculosis is extremely rare despite the high prevalence of this infection. Unfortunately, the diagnosis is often not suspected until surgery or at post-mortem. We report a case of an elderly Malay man presenting with massive gastrointestinal bleeding secondary to a tuberculous aorto-duodenal fistula in association with a saccular abdominal aortic aneurysm. This was successfully managed with an aortobifemoral graft repair and standard anti-tuberculous treatment for six months. A literature review of this rare condition is presented.

Radiological manifestations of melioidosis

Melioidosis is a serious infection that is associated with high mortality. It is due to a Gram-negative bacterium, Burkholderia pseudomallei which is an environmental saprophyte found in wet soils. Melioidosis is endemic to northern Australia and the Southeast Asia. However, there is now increasing number of reports of imported cases to regions where this infection has not been previously encountered. Almost any organ can be affected. Like many other conditions, radiological imaging is an integral part of the diagnostic workup of melioidosis. Awareness of the various radiological manifestations can help direct appropriate investigations to achieve early diagnosis and the initiation of appropriate treatment. Generally, there are no known characteristic features on imaging that can specifically differentiate melioidosis from other infections. However, the "honeycomb" appearance has been described to be characteristic for large melioidosis liver abscesses. Simultaneous involvement of various organs is also characteristics. To date, there are few data available on the radiological manifestations of melioidosis. The present pictorial essay describes melioidosis affecting the various organs.

Colorectal cancer: incidence and trend in Brunei Darussalam

INTRODUCTION

The incidence of colorectal cancer (CRC) is reported to be increasing. This study assessed the incidence and trend of CRCs in Brunei Darussalam, a developing nation.

METHODS

All histologically-confirmed CRCs over a 22-year period (1986-2007) were identified from the National Cancer and the Department of Pathology registries and retrospectively reviewed.

RESULTS

There was a total of 576 (male 59.0 percent, mean age 59.6 +/- 14.8 years, adenocarcinoma 97.6 percent, rectum 31.4 percent) CRCs diagnosed during this period. There was an increasing trend in the mean age at diagnosis, 55.2 +/- 17.5 years in 1986 to 62.0 +/- 13.0 years in 2007, but this was not significant (p-value equals 0.150, ANOVA). 18.8 percent were diagnosed in patients aged 45 years or below. There was no difference in the age at diagnosis between the genders (p-value equals to 0.432) and tumour sites, colon vs. rectum (p-value equals to 0.279). Overall, there was an increase in the age standardised rate (ASR) from 10.36 (1986-90) to 13.75 (1991-95), 15.90 (1996-2000), 16.87 (2001-05) and 24.31 per 100,000 (2006-07). Among the ethnic groups, the Chinese had higher ASRs (41.44) compared to the Malays (including the indigenous groups) with 15.46 per 100,000. The mean age of the Chinese (62.6 +/- 14.0 years) was significantly higher than that of the Malays (58.2 +/- 14.9 years, p-value equals to 0.001) at diagnosis. The age-specific incidence rates for the genders were comparable, except for the age groups of older than 55-59 years, where the rate for males was higher.

CONCLUSION

The incidence of CRC is increasing in our local setting with differences observed among the ethnic groups. The Chinese had a higher incidence but developed CRC at a later age. These have important implications if screening for CRC is to be considered in our local setting.

Impact of Ramadan on upper gastrointestinal endoscopy referrals in Brunei Darussalam

INTRODUCTION

Fasting during the month of Ramadan is one of the five holy pillars in the Islamic faith and is an obligation for all its followers. Prolonged fasting may precipitate or exacerbate gastrointestinal (GI) complaints. This study assessed the impact of Ramadan on referrals for upper GI endoscopy in a tertiary referral centre.

METHODS

1,661 patients referred to the centre a month before, during and a month after the month of Ramadan over a four-year period (2004-07) were retrospectively studied. Significant endoscopic findings were taken as any bleeding lesions, severe or complicated oesophagitis, peptic ulcer disease, portal hypertension related pathologies and malignancies.

RESULTS

Overall, there was significantly less workload generated during the fasting month (397 patients, 5.7 +/- 2.7 cases per list) compared to before (603 patients, 6.9 +/- 3.0 cases per list, p-value is equal to 0.036) and after (661 patients, 7.8 +/- 3.4 cases per list, p-value is less than 0.001) the fasting month. There was no significant difference between the period before and after the fasting month (p-value equal to 0.124). There were no significant differences in the mean age and gender of the patients. During the fasting month, there were differences in the ethnicity (fewer Malays and more Chinese, p-value is equal to 0.002) and referral sources (more wards and fewer clinics, p-value is less than 0.001). There were no differences in the referral indications, oesophageal and gastric findings, but there was a significant difference in the duodenal findings (p-value is equal to 0.001), especially ulcer disease, during the fasting month.

CONCLUSION

This study showed that significantly less workload was generated during the fasting month of Ramadan compared to the non-fasting months. There were also some differences in the referral sources, ethnicity and the endoscopic findings.

Gastrointestinal tuberculosis

Tuberculosis (TB) infection is still common and remains an important cause of morbidity and mortality, particularly in underdeveloped and developing nations. The gastrointestinal (GI) tract is the sixth commonest extrapulmonary site to be affected after lymphatic, genitourinary, bones and joints, miliary and meningeal involvement. Manifestations can be non-specific and mimic many conditions, including malignancies. Findings from endoscopy and radiological imaging are myriad, and depend on the stage of the disease and the time at which investigations are carried out. Hence, diagnosis can be difficult. Endoscopy is now the investigation of choice as it allows for visualisation and the sampling of tissue for histology and culture. This is complemented by radiological imaging. This pictorial essay reviews some of the endoscopic and radiological findings of non-human immunodeficiency virus associated proven GI TB infections that we have encountered in a tertiary referral centre.

Purple urine bag syndrome

Purple urine bag syndrome is a rare disorder where the plastic urinary catheter bag and tubing turn purple. The discolouration is due to the presence of indigo and indirubin pigments which are metabolites of tryptophan. It is associated with urinary tract infection. Bacteria that produce sulphatase and phosphatase are involved in the formation of these pigments. Purple urine bag syndrome is associated with higher morbidity and mortality, compared to urinary tract infection without this phenomenon. We present a case report of this rare phenomenon occurring in a 68-year-old woman.

Biliary strictures secondary to tuberculosis and early ampullary carcinoma

Obstructive jaundice is common and in most cases due to stone diseases or malignancies. Malignancies are important causes and are often unresectable at the time of diagnosis. Similarly, it is also important to consider infective causes such as tuberculosis (TB), particularly in endemic areas or in patients with risk factors. Although rare, the possibilities for the coexistence of different pathologies need to be considered as the treatment required will be different. We report a 67-year-old man with unexpected findings of obstructive jaundice secondary to biliary TB and an early ampullary tumour.