Colonic diverticula is observed in over 60% of the western population aged over 80 where up to 30% will eventually be symptomatic and may develop complications. The natural history and etiology of colonic diverticula have been well described. However, predictive indicators of complicated diverticular disease are not known thus preventing the prophylactic treatment of this subset of patients,. The aim of this study was to observe patients with complicated diverticular disease in order to identify common factors associated with recurrent complications. All hospital admissions from January 2005 to December 2008 for complications of diverticular disease were recruited. Using logistic regression, demographic data and factors such as clinical presentation, nature of complication, lifestyle, concomitant medical illness and medications that may be associated with recurrent episodes of complications were analyzed. A total of 121 patients were diagnosed with complicated diverticular disease during the study period with 24 patients having recurrent complications. Logistic regression analysis performed after controlling for confounders found active smoking (p=0.006) and alcohol consumption (p=0.036) along with underlying diabetes (p=0.031) and dyslipidemia (p=0.039) significantly associated with an increased risk of recurrent complications. We therefore concluded that smoking, alcohol consumption, diabetes mellitus and dyslipidemia are associated with recurrent complicated colonic diverticular disease. As these are modifiable risk factors, they should be sought for during the presentation of the first attack. Aggressive control of these factors will help in reducing the risk of recurrent complications.

Acute appendicitis is one of the most common differential diagnoses for acute abdominal pain made by emergency doctors. Suspected cases require surgical referral for observation or definitive intervention to prevent complications. A high index of suspicion and good clinical skills with the aid of scoring systems allows early decision making, which includes optimal pain control. The objective of this study was to identify the pain score and is relationship to the cut-off points of the Alvarado scoring system so that justifies early surgical referral or discharge for suspected acute appendicitis from the Emergency Department of Universiti Kebangsaan Malaysia Medical Centre (UKMMC). This was a cross sectional study of acute abdominal pain from June 2007 to September 2008. All patients who fulfilled the criteria and consented to the study were assessed for Alvarado score, verbal numerical pain score (VNRS) and their subsequent management. Patients with an Alvarado score of ≥7 were likely to have acute appendicitis (80.1% sensitivity and 52.63% specificity) and those with the score of ≤3 were unlikely to have acute appendicitis. The median pain score was 7.00 (IQR: 5.00-8.50) but 72.5% did not receive any analgesia. There was no direct relationship between the pain score with Alvarado score. Oligoanalgesia in patients with acute appendicitis still exist in Emergency Department of UKMMC.

Dermoid cyst in a kidney is rarely seen. We report a case of intrarenal dermoid cyst which mimics malignant renal tumour and discuss the dilemma in managing this disease.

Patients with end-stage renal disease typically require catheter hemodialysis during the time required for fistula or graft maturation or after other methods of hemodialysis are exhausted. When patients requiring indwelling catheters develop central venous occlusions, unconventional routes to the central veins are used. Translumbar catheterization of inferior vena cava is considered as one of the options for central venous access. We highlight a case of Translumbar central venous tunelled catheterization performed under Computed Tomography (CT) guidance combined with fluroscopy in a 40-year-old lady with end-stage renal failure.

Extra-gonadal germ cell tumours (EGGCT) are rare. Therefore further investigations of the testis is aimed at sourcing a possible primary origin of gonadal tumour. Over the years, various case series on EGGCT have been reported questioning its true nature as in a majority of them, a primary source is found in the testis, thus representing a metastatic gonadal tumour. The testis pathology could be either a true germ cell foci, an intra-tubular epithelial neoplasia or an area of fibrosis, indicating a ‘burnt out tumour’. We report a 39-year-old male who underwent laparotomy and excision of a retroperitoneal tumour. Histopathological examination revealed retroperitoneal lymph node of mixed germ cell tumour origin. Clinical and ultrasound examination of bilateral testis was normal. The patient refused orchidectomy or a testicular biopsy. He underwent four cycles of bleomycin, cisplatin, and etoposide with no evidence of tumour recurrence on follow up and remains disease free after 12 months of diagnosis. A literature review of EGGCT, its relation and factors relating with future testicular tumour is presented.

Pseudohyperkalemia is a spuriously high serum potassium measurement in a patient with no clinical evidence of hyperkalemia. It has been reported to occur in patients with leukocytosis and thrombocytosis. Only a few cases of pseudohyperkalemia have been reported in patients after splenectomy. Two cases of pseudohyperkalemia occurring after emergency splenectomy for abdominal trauma are presented to highlight their clinical presentation and sequalae. Consecutive patients who underwent emergency splenectomy for trauma and subsequently developed pseudohyperkalemia were monitored in Universiti Kebangsaan Malaysia Medical Centre for their clinical sequalae. Both the patients developed leukocytosis, thrombocytosis and high serum potassium level within 2-weeks of their splenectomies. They did not demonstrate any symptoms and signs of hyperkalemia. Their conditions resolved spontaneously without any specific treatment. Pseudohyperkalemia should be suspected in a similar clinical scenario to avoid unnecessary treatment that could lead to severe hypokalemia.

Management of pain plays an important role during prostate biopsy. Various types of management of pain plays an important role during prostate biopsy. Various types of anaesthetic methods have been used. The present study aimed to compare the efficacy and complication rate between periprostatic lidocaine infiltration and transrectal lidocaine gel in transrectal ultrasound guided prostate biopsy. All prostate biopsy patients were included except those with lidocaine, allergy, haemorrhagic diathesis, anticoagulation therapy, the inability to rate a visual analogue scale and inability to obtain consent. They were randomized into two groups. Group 1 received 20ml 2% transrectal lidocaine gel. Group 2 received 5ml 1% lidocaine infiltration for each periprostatic nerve block with 23-gauge spinal needle. After three minutes, prostate biopsy was performed with an 18 gauge 7-inch spring-loaded biopsy gun. Six biopsies were taken for each lobe. Pain during probe insertion, biopsy and immediately after the procedure was assessed using the Visual Analogue Scale. Any complication immediately after procedure, one day or after one week, was recorded. Mean pain score was lower after periprostatic lidocaine infiltration compared to transrectal lidocaine gel (3.1 + 1.9 versus 4.9 + 2.4, p = 0.027). There was no statistically significant difference in the complication rate. Transrectal ultrasound prostate biopsy using periprostatic lidocaine infiltration provides better anaesthesia as compared to the transrectal lidocaine gel application with no significant difference in complication. Thus, the use of periprostatic lidocaine infiltration in TRUS guided prostate biopsy is recommended.

Patients with Falciparum malaria may present with peripheral gangrene as a rare complication. In this report we describe two adult Sudanese patients with high grade fever for 10 days, jaundice, alteration consciousness and hypovolaemic shock. Both patients had blackish discolouration of the fore foot and the toes, bilaterally. Blood smears showed hyperparacitaemia with Plasmodium falciparum. They were diagnosed as having severe malaria with peripheral gangrene; they were treated with quinine infusion and the foot lesions recovered spontaneously without surgical intervention.

Tumour surgery for locally extensive malignant neoplasms of the extremity will sometimes result in extensive composite soft tissue defect. Local flaps are usually inadequate to cover these large defects. More than one tissue flap might be required to cover any exposed neurovascular structures, bone or prosthesis. We present two cases where two composite flaps were simultaneously used to cover extensive surgical defects after ablative tumour resections in the extremity. These resulted in uncomplicated wound healing and limb salvage.

Morbidly adherent placenta with spontaneous rupture of membrane at extreme prematurity poses poor pregnancy outcome. Various issues on different management modalities still remain perplexed and individual consideration is vital. Two cases of morbidly adherent placenta with symptomatic per vaginal bleeding and spontaneous rupture of membrane at severe prematurity were reviewed and discussed. We found that, active intervention by termination of pregnancy and methotrexate therapy at early gestation can prevent the need of hysterectomy following major obstetrics haemorrhage.